Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and no basis exists for the Plan to deny coverage. The Plan says that the denial of payment for this testing is correct, because this testing is considered experimental.
We decided that the Plan has to pay for GeneSight test (test code 81479).
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.
GeneSight testing was ordered by an in-network provider. The file does not show that the plan provided notice that GeneSight would not be covered. Under Medicare rules, this means GeneSight is considered approved by the plan. Therefore, we decided that the Plan has to pay for GeneSight test.
We also decided that the Plan does not have to pay for MTHFR test (test code 81291).
The Plan follows Medicare rules. Medicare rules state that MTHFR genotyping has no clinical utility in any clinical scenario and is not a Medicare-covered benefit. Because MTHFR testing is never covered by Medicare, and the Plan Evidence of Coverage clearly states that services excluded from Medicare coverage are never covered by the Plan unless offered through a supplemental benefit, this non-coverage cannot be overridden by plan-directed care. Therefore, we decided that the Plan does not have to pay for MTHFR test.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visits coded as 97018,
97110, 97140 and 97165 provided February 5, 2021 to April 26, 2021.
You asked the Plan to waive the copayment for the outpatient visits. You say that you were never told the cost
and they were repeating things you could have easily done at home. The Plan denied your request. The Plan
says the claims were processed with the correct copayments applied per the Evidence of Coverage.
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 $35
copayment for each Medicare covered physical therapy and speech-language therapy visit and $35 for each
occupational therapy visit.
You have been asked to pay $665 ($175.00 for 5 visits in February + $280.00 for 8 visits in March + $210.00
for 6 visits in April) for the outpatient visits. The outpatient visits fall within the Outpatient rehabilitation
services 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 copayment for the physical therapy visits
coded as 97018, 97110, 97140 and 97165 provided February 5, 2021 to April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the allowed amount for the porcelain crown (D2740) for
tooth # 14 provided on April 15, 2021.
You asked the Plan to reimburse the allowed amount for the dental service. You say that it is your
understanding that you were advised by a plan representative that the reimbursement amount for a crown is
$668. You also say that you should be reimbursed this amount. The Plan denied your request. The Plan says the
provider in this case is out of network. The Plan says that dental services received out of network are paid
based on the maximum allowable charge (MAC). The Plan says there is a 50% coinsurance for a crown. The
Plan also says out of network dentists may bill you for any amount greater than what the plan pays.
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 and crowns are listed as covered, dental
services that are received out of network are paid based on the allowed amount, in this case that is $668. There
is a 50% coinsurance that applies to crowns, $668 x 50% = $334. Additionally, out of network providers may
bill you for the difference between what the provider billed, or $1,199, and the plan pays, or $334. $1,199 -
$334 = $865. Therefore, we decided that the Plan does not have to reimburse the allowed amount for the
porcelain crown (D2740) for tooth # 14 provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary and reasonable. The Plan denied your request. The Plan says rules for IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the patient was admitted for rhabdomyolysis after a fall. Medical problems are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 31, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. You have not submitted documentation to support the billed Place of Service (POS) code of 81 - indicating an independent laboratory setting. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided on February 6, 2021.
You asked the Plan to pay for an inpatient admission. The Plan denied your request. The Plan says you received services from a provider who is not under contract with the health Plan and has opted out of Medicare and services that are not covered by the Plan.
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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided on February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99100) provided on October 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99100). Based on
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99100) provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on the enrollee on May 28,
2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for physician services provided on the enrollee on
May 28, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient mental health care you received on May 27, 2021.
You asked the Plan to waive the deductible for the outpatient mental health care services. You say that you don't believe the services you received warranted the charges. You say that this doctor did not tell you he was a psychiatrist. The Plan denied your request. The Plan says this deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to outpatient mental health services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient mental health services. This cost sharing is a contractual obligation that had not been met at the time the outpatient mental health care services was received on May 27, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for outpatient mental health care you received on May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on August 27, 2020.
You asked the Plan to pay for lab tests. You say that this testing is necessary and very effective. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation
submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing
was taken in a nursing facility setting, therefore the POS code 11 - indicating an office setting - is not
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests
have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on
August 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing and/or
skilled therapy services on a daily basis. Although further rehabilitation services would be appropriate to
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care
than a skilled nursing facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular risk genetic testing panel provided on January 20, 2021.
You asked the Plan to pay for the comprehensive cardiovascular risk genetic testing panel. You say that this is not experimental testing and is covered by Medicare. The Plan denied your request. The Plan says this is considered screening testing.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem and who will use the results in the management of the specific problem. We looked at the file and Medicare rules. In the certificate of medical consultation, it is noted only that the ordering physician spoke to the enrollee about a history of heart attack and use of blood pressure medications.
It is not noted that a full examination was done. Furthermore, the note states that the enrollee should follow up on the results of the testing with his primary care and cardiology physicians. As such, it is documented that the results will not be used by the ordering physician for the management of any specific problem. Based on this information, we decided that Medicare rules for coverage of the comprehensive cardiovascular risk genetic testing panel have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular risk genetic testing panel provided on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you will benefit from IRF care to improve overall
functional mobility and safety prior to returning home. The Plan denied your request. The Plan says an
intensive rehabilitation program is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479, 81521) provided May 13, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The records do not show that the enrollee's treating physician ordered
the tests. Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for lab services (81479, 81521) provided
May 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services billed with a PDPM score of GCGE1 x 19 days and provided on May 13, 2020, through May 31, 2020.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support a diagnosis coding of malnutrition.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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 the documentation submitted does not support PDPM GCGE1 x 19 days. Our reviewer found the documentation does not support a diagnosis of malnutrition. 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 SNF services billed with a PDPM score of GCGE1 x 19 days and provided on May 13, 2020, through May 31, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on May 29, 2021.
You asked the Plan to pay for lab tests. You say that the Plan is required to pay for these services if they would have otherwise been covered if provided by an in-network provider. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and in-network providers were available.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 specify whether the ordering provider was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on May 29, 2021.