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

We decided that the Plan does not have to pre-approve implant of an infusion pump.
You asked the Plan to pre-approve implant of an infusion pump. 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 follows Medicare rules. Medicare rules say that implantation of an infusion pump is covered when specific coverage is met. 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 implant of an infusion pump. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has another implanted, programmable device. The elements of the coverage criteria are not
satisfied. The requested service is not 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 implant of an infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve implant of an infusion pump.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on August 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for practitioner visit. You say that your physician provided care without requesting authorization to avoid a delay in care. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 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 a practitioner visit provided on August 18, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 22, 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 must 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 out of network physician services provided to the enrollee on April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 hours per day of services of home health aide (HHA) (G0156) and direct skilled nursing services of a registered nurse (RN) (G0299).

You asked the Plan to pre-approve the 3 hours per day of HHA services and skilled nursing services of a RN. The Plan denied your request. The Plan says you do not require hands-on assistance with at least 2 activities of daily living.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 3 hours per day of HHA services and skilled nursing services of a RN. Our reviewer says that more than the approved 1.45 hours per day of services of a HHA (G0156) and direct skilled nursing services of a RN (G0299) are medically reasonable and necessary. Our physician reviewer found there is no documentation that the 1.45 hours per day of services of a HHA (G0156) and direct skilled nursing services of a RN (G0299) are inadequate to treat your condition. 

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 3 hours per day of HHA services and skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 hours per day of services of home health aide (HHA) (G0156) and direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ER visit provided on May 20, 2021.

You asked the Plan to pay for the ER visit. You say that the patient was not enrolled in hospice on this date of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on May 7, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ER visit provided on May 20, 2021.
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 the enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehabilitation services at a lower level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (G0453-59) provided on July 19, 2021.

You asked the Plan to pay for intraoperative neurophysiology monitoring. You say that this was medically necessary. The Plan denied your request. The Plan says the records do not support modifier -59.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records show that this was performed during the same encounter and procedure as the other billed services. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (G0453-59) provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81406, 81407, 81408, and 81479 provided on May 25, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 81406, 81407, 81408, and 81479 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Review of the file does not show that only one code was submitted for the services provided. Based on this information, we decided that Medicare rules for coverage of the laboratory services
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81406, 81407, 81408, and 81479 provided on May 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services provided on February 20, 2021.
You asked the Plan to pay for hospital discharge day management services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services provided on February 20, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on August 4, 2021.

You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on August 4, 2021.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve private duty nursing.

You asked the Plan to pre-approve private duty nursing. 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 home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 private duty nursing. Our reviewer says that the services are not medically necessary. Our physician reviewer found skilled nursing and nursing aide services beyond 35 hours per week are not a covered benefit under the Medicare home health program. Services beyond 35 hours per week are private duty nursing which is not a covered benefit under the Medicare home health program. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of private duty nursing have not been met. Therefore, we decided that the Plan does not have to pre-approve private duty nursing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator electrode.

You asked the Plan to pre-approve percutaneous implantation of a neurostimulator electrode. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided. coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 percutaneous implantation of a neurostimulator electrode. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient literature to support the use of the requested service for the enrollee's specific clinical condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not 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 percutaneous implantation of a neurostimulator electrode have not been met.

Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of a neurostimulator electrode.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a genetic panel (81270, 81279, 81338) provided on June 16, 2021.

You asked the Plan to pay for a genetic panel. You say that this was medically necessary. 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. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so 1 code must be submitted for the panel. 

We find that CPT codes 81270, 81279, and 81338 are not supported in the medical record. Specifically, these codes were used to report a panel, which should be billed with one code. Based on this information, we decided that Medicare rules for coverage of a genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a genetic panel (81270, 81279, 81338) provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided August 21, 2021.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that to report a pharmacogenomics testing service, providers must enter one unit of service of the correct procedure code and enter the appropriate DEX Z-Code identifier adjacent to the procedure code. 

We looked at the file and Medicare rules. The claim did not include an appropriate Z-Code. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided August 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram with digital breast tomosynthesis you had on July 29, 2021.

You asked the Plan to waive the deductible for the diagnostic mammogram with digital breast tomosynthesis. You say that you went for a breast screening and they coded it wrong. The Plan denied your request. The Plan says you had not yet met your deductible at the time of these services.

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 $300 in-network deductible which applies to diagnostic testing services. 

We looked at the medical records in this case to determine the type of services you received. The medical records clearly indicate that the mammogram you had was ordered for diagnostic purposes. The records show that your doctor ordered this service due to left breast cancer for which you underwent a lumpectomy and radiation. This test was not performed as a screening. That is why the diagnostic mammogram falls within the benefit category of diagnostic testing services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 in-network deductible which applies to diagnostic testing services. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram with digital breast tomosynthesis were received on July 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram with digital breast tomosynthesis you had on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography, head or brain (70450) provided May 1, 2021.

You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. Attached reports to support the level of service. Please reconsider for processing. The Plan denied your request. The Plan says the records do not support the service billed.

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 the CT scan 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 computed tomography, head or brain (70450) provided May 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab, Carboplatin, and Etoposide.
You asked the Plan to pre-approve Atezolizumab, Carboplatin, and Etoposide. You say that the medication is 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 a drug or biological only if it is safe and effective and otherwise reasonable and 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 Atezolizumab, Carboplatin, and Etoposide. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria 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 Atezolizumab, Carboplatin, and Etoposide have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab, Carboplatin, and Etoposide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the shoulder brace you received on June 20, 2021.  

You asked the Plan to waive the coinsurance for the shoulder brace. You say that you do not believe you or the plan should have to pay for this.  

You said that this claim should go to worker's compensation. The Plan denied your request. The Plan says you were assessed this coinsurance 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 20% coinsurance for prosthetic devices.   

You have been asked to pay 20% coinsurance for the shoulder brace. The shoulder brace falls within the prosthetic devices 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 shoulder brace you received on June 20, 2021.   

Your complaint about this claim being paid by Worker's compensation insurance 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.