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

We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on September 30, 2019 at the LD1 payment level.
You asked the Plan to pay for the SNF services at the KD1 payment level. You say that you would like reconsideration because the documentation supports the code that was billed. The Plan denied your request. The Plan says the documentation supports AAAx1 day.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services at the KD1 payment level have not been met. Specifically, the record does not include a Resource Utilization Group 5 day assessment. The documentation submitted does not support payment at the KD1 level. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on September 30, 2019 at the LD1 payment level.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan of the body from head to thighs for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for first staging of prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found per the package insert, this scan is approvable for men with a rising prostate specific antigen (PSA) after treatment. It is not recommended for initial staging. 

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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan of the body from head to thighs for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for imaging services (procedure code 73600) provided to the enrollee on July 21, 2021.
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 this is bundled to another service billed on the same day by the same provider.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 73600 is "Radiologic examination, ankle; 2 views." 

We asked our coder 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 services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found the documentation submitted consists of an x-ray documenting one view for date of service July 21, 2021 with claim number 82021206001. No additional documentation was found to support another claim for CPT 73610 was performed and billed for the same date of service. Therefore, this service should be covered. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for imaging services (procedure code 73600) provided to the enrollee on July 21, 2021.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says your records show you do not need to be seen by a rehab doctor three (3) times a
week. The Plan states the records do not show you can yet tolerate or need 3 hours of therapy a day, five (5)
days a week. The Plan states you do not need an intensive team for your care, and you can safely receive the
services you need in other settings, for example: a skilled nursing facility, home with home health services or
home with outpatient therapy.
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 complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a telehealth individual mental health session (99214) rendered on April 2, 2021.
You asked the Plan to waive the copayment for a telehealth individual mental health session. You say that the services should be covered because you were not getting the medical help you needed from that office. The Plan denied your request. The Plan says you have been charged the correct copayment amount.
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 telehealth individual mental health sessions are covered, however, you must pay a $35 copayment for each individual mental health session.
You have been asked to pay a $35 copayment for an individual mental health session. Individual mental health sessions fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a telehealth individual mental health session (99214) rendered on April 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on March 21, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.

The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. 

We looked at the file and Medicare rules. In this case, the records do not show that the CP consulted the enrollee's attending/PCP. Additionally, there is no referring physician listed on the claim. 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 outpatient mental health services provided on March 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2750), and resin-based composites (D2391),
(D2331), and (D2393) provided by a participating provider on July 20, 2021.

You asked the Plan to pay for a crown and resin-based composites. You say that the Plan should have told you
that your allowance went from $2,000 to $1,000. The Plan denied your request. The Plan says the correct
member liability amount has been applied.

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. The Plan covers a crown and
resin-based composites up to a benefit limit of $1,000 in 2021.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a crown and resin-based composites have been correctly applied. The total amount for these
services is $1,206. The Plan has paid a total of $903. The total amount you are being asked to pay is $303. The
record shows that you have exhausted the Plan benefit limit of $1,000 for dental services in 2021. Therefore,
we decided that the Plan does not have to pay for a crown (D2750), and resin-based composites (D2391),
(D2331), and (D2393) provided by a participating provider on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 had network providers
available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on February
9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on May 21, 2021.
You asked the Plan to pay for eyeglasses. You say that you were told by several Plan agents that because you have an allowance of $200.00 that you will be reimbursed for as many pairs up to $200.00. The Plan denied your request. The Plan says you have exceeded the Plan benefit for the year with one pair of glasses, the member is responsible for the second pair of glasses (frames and lens).
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on May 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
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 the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the podiatry visit you had on June 16, 2021.
You asked the Plan to reduce the copayment for the podiatry visit. You say that you have had many visits with this provider and have never had to pay this much. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($35.11) is less than your copayment obligation, you are responsible for the full allowed amount. The Plan also stated that you changed your plan in April and as a result, your copayment increased from $15 to $45 for podiatry services.
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 $45 copayment for podiatry services. You have been asked to pay a $45 copayment for the podiatry visit. 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 reduce the copayment for the podiatry visit you had on June 16, 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 you do 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 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 Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81301, 81308, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on April 29, 2021.

You asked the Plan to pay for Guardant360 testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that code 81479 is used for Guardant360 testing.

We find that CPT codes 81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81301, 81308, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, and 81406 are not supported in the medical record. Specifically, these codes were used to bill for Guardant360 testing, which should be reported with 81479. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81120, 81121, 81173, 81201, 81210, 81235, 81270, 81272, 81275, 81293, 81301, 81308, 81309, 81310, 81311, 81314, 81318, 81321, 81400, 81401, 81402, 81403, 81404, 81405, 81406) provided on April 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on
October 7, 2020.

You asked the Plan to pay for the evaluation and management service. You say that the services were
medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the
last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify
the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on
October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided May 5, 2021.

You asked the Plan to pay for the CT scan of the head or brain. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim was not billed with an appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain (70450) provided May 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the infusion services rendered on February 26, 2021.
You asked the Plan to waive the coinsurance for these services. You say that the services were covered at 100 percent in 2020. The Plan denied your request. The Plan says the coinsurance was applied 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 20% coinsurance for Medicare Part B chemotherapy drugs and other Medicare Part B drugs.
Review of the file shows that you received infusion on February 26, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B chemotherapy drugs and other Medicare Part B drugs 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 the infusion services rendered on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the lenses provided on June 20, 2021.

You asked the Plan to pay more for the lenses. You say that these are necessary prescription sunglasses. You say that your plan will pay a large dollar amount for lenses and something should be covered. The Plan denied your request. The Plan says the claim processed correctly.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $100 every 2 calendar years for eyewear. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Specifically, the Plan paid $100 toward the frames and lenses purchased on June 20, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the lenses provided on June 20, 2021.