Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from August 14, 2020, to August 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that there are inconsistencies between the documentation in the medical records and the coding of the 5 day Minimum Data Set (MDS) assessment.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not make any specific argument as to which functional abilities were felt to be incorrectly scored. The plan has not provided enough evidence to claim that the assessment coding was not done correctly. The plan has not stated what else the provider needs to send in for payment of the claim. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) services provided to the enrollee from August 14, 2020, to August 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), an intraoral periapical radiographic image (D0220) and three (3) tooth extractions (D7140, D7210) provided on July 16, 2021.
You asked the Plan to pay for these dental services. You say that you will not be able to pay the amount due on the claim and would like the Plan to waive your payment responsibility. The Plan denied your request. The Plan says there is no coverage for a periapical radiographic image, extractions or a limited oral evaluation. The Plan also says you did not contact the Plan prior to the date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited
oral evaluation (D0140), an intraoral periapical radiographic image (D0220) and three (3) tooth extractions
(D7140, D7210) provided on July 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing service (G0480) rendered by the out-of-network (OON) provider on July 16, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the drug testing service (G0480) rendered by the out-of-network (OON) provider on
July 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 6 to August 18, 2021.
You asked the Plan to pay for psychotherapy services. You say that you were advised by the Plan in December to reach out to an out-of-network provider to address your issues. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on January 6 to August 18, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay a separate payment for the inpatient readmission provided from December 30, 2020, through January 4, 2021.
You asked the Plan to pay a separate payment for the inpatient readmission. The Plan denied your request. The Plan says that the Plan will not recognize and reimburse another DRG for members that are readmitted to the same facility for symptoms related to, or for the evaluation and management of the prior stay's medical condition within 30 calendar days.
The Plan follows Medicare Rules. Medicare rules say that inpatient readmission is covered when medically necessary, and if the readmission did not result from a premature discharge from the same hospital. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an inpatient admission. Our reviewer says that the Medicare rules for separate payment of the readmission have not been met. Our physician reviewer found the enrollee is a 68-year-old male who presented to the hospital and was readmitted for worsening respiratory status following recent (2 days prior) discharge from the hospital for hypoxic respiratory failure related to Coronavirus (COVID-19) pneumonia. Upon discharge from the first admission, antibiotics and IV steroids were stopped. The enrollee began worsening again 2 days after discharge. The readmission was medically necessary as he had progressively worsened acute respiratory failure. The readmission appears to have resulted from a relatively premature discharge from the same hospital as treatments were discontinued upon discharge in a patient that is at high risk of slow improvement from Coronavirus (COVID-19) infection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage for separate payment of the inpatient readmission have not been met. Therefore, we decided that the Plan does not have to pay a separate payment for the inpatient readmission provided from December 30, 2020, through January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (L0637) provided on February 8, 2021.
You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that you want a more reasonable price. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics.
You have been asked to pay $161.50, or 20% of the Medicare-allowed charge of $807.50, for a lumbar-sacral orthosis. A lumbar-sacral orthosis falls within the "Prosthetic devices and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a lumbar-sacral orthosis (L0637) provided on February 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on December 11, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you went to the ER but were admitted for the same condition three days later. You stated that you should not have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for emergency room visits. You have been asked to pay a $100 copayment for the ER visit. According to your Evidence of Coverage, if you are admitted to the hospital within 24 hours for the same condition you pay $0 for the emergency room visit. You were admitted three days after your ER visit according to your appeal, so you would not qualify for a copayment waiver under your Plan's Evidence of Coverage. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on December 11, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) and gingival irrigation (D4921) provided on June 14, 2021.
You asked the Plan to pay for periodontal scaling and root planing and gingival irrigation. You say that you are being denied for a service that you did not know needed authorization. You spoke with the Plan and they did not mention a prior authorization was needed for a periodontal scaling and root planing and that gingival irrigation was not covered. The Plan denied your request. The Plan says prior authorization is needed for a periodontal scaling and root planing. The Plan also says that gingival irrigation is not a covered benefit with your Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. The EOC confirms that a periodontal scaling and root planning is a covered benefit, however, prior authorization is needed. The EOC also confirms that gingival irrigation is not listed as a covered benefit with your Plan. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing and gingival irrigation have not been met. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) and gingival irrigation (D4921) provided on June 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing service (G0480) rendered by the out-of-network (OON) provider on August 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing service (G0480) rendered by the out-of-network (OON) provider on August 4, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on September 14, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you did not self-administer any drugs while you were in the hospital. You also say that the doctor gave you a pain injection and prescription for a pain cream. The Plan denied your request. The Plan says self-administered drugs are not covered while you are in the hospital. The Plan also says that you are responsible for this amount.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on September 14, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical first radiographic image (D0220), an intraoral periapical additional radiographic image (D0230) and a full mouth debridement to enable a comprehensive oral evaluation (D4355) provided on September 16, 2021.
You asked the Plan to pay for dental services. You say that you spoke with the provider's office prior to the enrollee's appointment. You explained that the enrollee could not afford anything outside of what the Plan covers. The provider was supposed to do only what the policy covered which was a standard cleaning and x-rays. You are requesting a refund. The Plan denied your request. The Plan says the services at issue are not a covered benefit with the enrollee's Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral periapical first radiographic image (D0220), an intraoral periapical additional radiographic image (D0230) and a full mouth debridement to enable a comprehensive oral evaluation (D4355) provided on September 16, 2021.
Your complaint about the provider's office is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) panel provided on
June 1, 2021 billed with code 81455.
You asked the Plan to pay for the F1Heme panel. You say that this is medically necessary testing. The Plan denied your request. The Plan says this code is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients hematolymphoid disease for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare. We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) panel provided on June 1, 2021 billed with code 81455.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
April 17, 2021, through April 28, 2021.
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment should be made
for these services. The Plan denied your request. The Plan says other than the approved dates, the enrollee did
not require daily skilled care. The stay was custodial beyond 4/16.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found as of 4/16/2021, the member did not
require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with
mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective
maintenance program. As a practical matter, the member did not require any skilled services on an inpatient
basis, at a SNF level of care as of 4/16/2021.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided from April 17, 2021, through April 28,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography of the thorax, diagnostic; without contrast material (71250) provided on June 1, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
Your contract with the Plan clearly says that you must pay a $50 copayment for an in-network, Medicarecovered
complex diagnostic test and/or radiology visit.
You have been asked to pay a $50 copayment for the in-network, Medicare-covered complex diagnostic test
provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the computed tomography of the thorax,
diagnostic; without contrast material (71250) provided on June 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 15, 2021, to September 6, 2021.
You asked the Plan to pay for the SNF care provided from August 15, 2021, to September 6, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF care provided from August 15, 2021, to September 6, 2021. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care provided from August 15, 2021, to September 6, 2021 have not been met. Specifically, the file shows that the enrollee did not receive daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 15, 2021, to September 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64494) provided on May 25, 2021.
You asked the Plan to pay for facet joint injections. You say that this is supported in the records. The Plan denied your request. The Plan says this exceeds MUE.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of facet
joint injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint
injections (64494) provided on May 25, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99344) rendered by the out-of-network (OON) provider on August 17, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99344) rendered by the out-of-network (OON) provider on August 17, 2021.