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

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on SNF criteria. The Plan states the
enrollee can receive the care they need in another setting, such as home, a long-term care facility or other
outpatient setting.
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 there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing
or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria
for 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee was sent home with
this item to use post-surgery. The Plan denied your request. The Plan says this device is not covered by
Medicare.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for a pneumatic compression device (E0676).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 24, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is included in the payment to the facility.

Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on June 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on August 1, 2021.
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 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 services (70450) provided on August 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided to the enrollee on February 28,
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 the denied code is not supported in the records submitted.
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 49905 is "Omental flap, intra-abdominal (List separately
in addition to code for primary procedure)."
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 not supported by the medical records. Our reviewer found the operative report does not include
enough detail to confirm this procedure was performed. The report describes a perforation was identified, and
closed with vicryl sutures. An omental patch was developed, taking the right lateral aspect of it and placement
over the perforation site and sutured in place. Surgical report does not contain enough information to confirm
this procedure has been performed.
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 not been met. Therefore, we decided that the Plan does not
have to pay for inpatient services provided to the enrollee on February 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
separately payable
.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the lab services provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99308) provided on August 
3, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for subsequent nursing facility care. You say that the treatment rendered to the 
patient was medically necessary per the physician that provided the services. You have also submitted 
supporting documents. The Plan denied your request. The Plan says these services were not authorized. The 
Plan also says that this provider is a non-contracted provider who performed services to the member without 
prior authorization from 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 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 subsequent nursing facility care (99308) provided 
on August 3, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
January 14, 2021, through January 25, 2021, February 2, 2021, through February 12, 2021, and February 21,
2021, through March 5, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share 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 $275
copay each day one through five per each admission for inpatient hospital care.
You have been asked to pay a $275 copay each day one through five per each admission for the inpatient
hospital care. This service falls within the inpatient hospital care benefit category. The records indicate you
were admitted to the hospital on three separate occasions with stay lasting more than five days. 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 inpatient hospital care provided on January 14, 2021, through
January 25, 2021, February 2, 2021, through February 12, 2021, and February 21, 2021, through March 5,
2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a 4Kscore test provided on August 20, 2021.
You asked the Plan to pay for a 4Kscore test. The Plan denied your request. The Plan says that based on
Medicare guidelines, the oncology prostate prob score (4Kscore) you are requesting do not satisfy Medicare
guidelines for approval. The enrollee's diagnosis is concern for prostate cancer. The limited medical record
shows that the enrollee is 54 years of age and has a prostate-specific antigen (PSA) level of 2.43, and that this
testing is being performed as a screening test.
The Plan follows Medicare rules.
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 a 4Kscore test. Our reviewer says that the
4Kscore test was not medically necessary. Our physician reviewer found the reviewed documentation indicates
that the provider states that the enrollee is 54 years of age and has a PSA level of 2.43, and that this testing is
being performed as a screening test. The review has determined that the requested 4Kscore test at issue in this
case does not meet the Medicare LCD criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a 4Kscore test have not been met. Therefore, we decided that the Plan does not
have to pay for a 4Kscore test provided on August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943), 
the electrical stimulation (G0283), and transcutaneous electrical nerve stimulation (E0730) provided on August 
6, 2021.

You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says these services are not among those 
covered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are all not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatment (98943), the electrical 
stimulation (G0283), and transcutaneous electrical nerve stimulation (E0730) provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tempus gene panel testing provided on May 11, 2021.  You asked the Plan to pay for the testing services. You say that the panel takes a deep look into tumor biology. The Plan denied your request. The Plan says the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The claim information show that the panel testing was billed with multiple codes. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. The claim also lists a place of service as an independent laboratory. The records do not show that the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus gene panel testing provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on July 28,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that the treatment rendered to the
patient was medically necessary per the physician that provided the services. You also say that you have
provided supporting records. The Plan denied your request. The Plan says these services were not authorized,
and all services provided to the member must be 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 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 domiciliary or rest home visit (99335) provided
on July 28, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement lower limb prosthesis.
You asked the Plan to pre-approve the replacement prosthesis. You say that it is felt that a new prosthesis is the
best option. The Plan denied your request. The Plan says criteria for a new leg are not met in this case, though a
new socket would be approved if requested.
The Plan follows Medicare rules. Medicare rules say that replacement of an existing leg prosthesis is
considered medically necessary when certain criteria are 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 the replacement prosthesis. Our
reviewer says that the documentation does not support the medical necessity of a replacement prosthesis.
Our physician reviewer found the enrollee is a 79-year-old man who underwent a left above-knee amputation
on 6/8/2020 due to an aneurysm, blood clot, and infection that followed. The physician writes on 1/5/2022 that
the enrollee has undergone physiological changes (volume fluctuation/loss). As a result, there is a large gap in
the upper part of his socket, and it is no longer fitting him properly.
While the documentation supports that the enrollee in this case has undergone physiological changes, a
replacement socket prosthesis would be sufficient to meet the enrollee's needs. The documentation does not
support that the coverage criteria for a new prosthetic leg with an electronic knee and advanced foot are met in
this case.
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 replacement prosthesis have not been met. Therefore, we decided that the
Plan does not have to pre-approve a replacement lower limb prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth (D7230) and problem focused limited oral evaluation (D0140) provided on September 15, 2021.
You asked the Plan to pay for the removal of an impacted tooth and problem focused limited oral evaluation. You say that you feel you did everything that was expected of you to make sure these services would be covered. The Plan denied your request. The Plan says the removal of an impacted tooth is not a covered benefit under your dental plan. The Plan also says that the problem focused limited oral evaluation exceeds the frequency limitation in your benefit 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 removal of an impacted tooth (D7230) is not among those covered under this benefit. The contract says that problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 28, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the removal of an impacted tooth (D7230) and problem focused limited oral evaluation (D0140) provided on September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550, 83970, 84100, 84460) provided to the enrollee on March 3, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the documentation submitted by the laboratory failed to show that the laboratory 
tests reported were unrelated to treatment of ESRD; therefore, in accordance with Centers for Medicare & 
Medicaid Services (CMS), the laboratory tests are the responsibility of the dialysis center and are not separately 
reportable by the laboratory.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows 
that there is no modifier to indicate this would be separate from ESRD. The medical records also indicate that 
these lab services were related to ESRD. Therefore, we decided that the Plan does not have to pay for the 
laboratory services (CPT code(s): 82310, 82728, 83540, 83550, 83970, 84100, 84460) provided to the enrollee 
on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (LTACH).

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 there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital.

The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided on August 
24, 2021
.
You asked the Plan to waive the coinsurance for the surgery. You say that the surgery was billed wrong and 
should not have been in an outpatient hospital. The Plan denied your request. The Plan says the surgery was 
billed correctly, and 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 a 20% 
coinsurance for In-Network surgery performed at an Outpatient Hospital Facility. The total amount allowed 
was $10,959.64 and the coinsurance was $2,191.93 ($10,959.64 total cost x 20% coinsurance).

You have been asked to pay a 20% coinsurance for an In-Network outpatient surgery. Outpatient surgery falls 
within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers 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 an outpatient surgery provided on August 24, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on September 20, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you did not have a good experience previously with another dentist and wanted to go to a new dentist's office for services. You are requesting reconsideration. The Plan denied your request. The Plan says you have exceeded the frequency of this service.
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 intraoral complete series of radiographic images once every five years.
We looked at the file and Medicare rules. The records show that you received an intraoral complete series of radiographic images on September 7, 2021, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of intraoral complete series of radiographic images have not been met. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on September 20, 2021.