Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99000) provided on February 22, 201.

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. Code 99000 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 this service. 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 (99000) provided on February 22, 201.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dry needling services from a physical therapist.
You asked the Plan to pre-approve the dry needling services. You say that your physical therapist has a unique ability to relieve intense chronic lower back pain with the combination of dry needling, manipulation, and ultrasound with moist heat. You say that this treatment has helped you avoid back surgeries. You say that your physical therapist has requested a minimal payment for dry needling. You say that it is unfair that acupuncture is covered but that this requested service is not. The Plan denied your request. The Plan says Medicare coverage rules have not been met for the requested treatment.
The Plan must follow Medicare rules. The rules say that Medicare offers limited coverage for acupuncture/dry needling treatments for CLBP meeting certain requirements. These requirements include a limitation on the types of providers who can supply the service.
We looked at the file and Medicare rules. The records show that the provider you are requesting the dry needling through is a physical therapist who does not have a masters or doctoral level degree in acupuncture or Oriental Medicine. Based on this information, we decided that the rules for coverage of the dry needling services have not been met. Therefore, we decided that the Plan does not have to pre-approve dry needling services from a physical therapist.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99334) provided on April 22, 2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that at the time of the service, the enrollee advised you that she was covered under Medicare. You also say that it was impossible to obtain an authorization due to being misled by the enrollee. The Plan denied your request. The Plan says this service was rendered by an OON provider. The Plan also says that this service was not approved in advance.
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 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 the domiciliary or rest home visit (99334) provided on April 22, 2021 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient surgery provided on April 7, 2021.
You asked the Plan to waive the deductible for the outpatient surgery. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.
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 $200 deductible which applies to Outpatient surgery.
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $200 deductible which applies to Outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery was received on April 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient surgery provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on January 8, 2021.

You asked the Plan to pay for ConfirmMDx testing. You say that this was ordered separately from the enrollee's biopsy. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.

We looked at the file and Medicare rules. The records show that the enrollee has not had a cancer-negative biopsy and had been diagnosed with cancer prior to this testing. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551) provided on January 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hypokalemia after recent abdominal hematoma evacuation and right hip arthroplasty. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Part B injection (J0604) provided from May 1, 2020 to January 31, 2021.
You asked the Plan to pay for the Part B injection (J0604). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming the administration of the Part B injections on the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the Part B injection (J0604) provided from May 1, 2020 to January 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 vaccine provided on March 27, 2021.

You asked the Plan to pay for the COVID-19 vaccine. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the claim should be submitted to the MAC for the enrollee's jurisdiction.

The Plan must follow Medicare rules. Pursuant to CMS guidance Medicare payment for COVID vaccinations
administered during calendar years 2020 and 2021 to MA beneficiaries will be made through the Medicare FFS
program.

We find that the claim should be billed to the Original Medicare MAC. Therefore, we decided that the Plan
does not have to pay for the COVID-19 vaccine provided on March 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone (D7210), limited oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), and placement of intra-socket biological dressing to aid in hemostasis (D7922) provided February 4, 2021.

You asked the Plan to pay for the tooth extraction, limited oral exam, panoramic x-ray and intra-socket biological dressing. You say that you had issues finding an in-network dentist to do the extractions and should not be responsible for the cost. The Plan denied your request. The Plan says this provider has opted out of Medicare and is not part of the Plan's network of providers, and therefore the services are not covered.

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 the tooth extraction, limited oral exam, panoramic x-ray and intra-socket biological dressing when the services are provided by a network dentist.

We looked at the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Additionally, the requested provider in this case is not a network provider with the Plan. 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 the extraction, erupted tooth requiring removal of bone (D7210), limited oral evaluation - problem focused (D0140), panoramic radiographic image (D0330), and placement of intra-socket biological dressing to aid in hemostasis (D7922) provided February 4, 2021. 

Your complaint about having difficulty locating a provider and potentially being provided misinformation by the a Plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found based on the provided documentation, you are not suggested to require hospital services that would likely cross 2 midnights for this typically ambulatory procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
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 this will help you recover faster. The Plan denied your request. The Plan says you can be treated at a lower level of care.
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 and an intensive rehabilitation therapy program.
While the documentation does support a need for physical or occupational therapy, there is no documented need for a 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (63047) provided on November 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE value has been exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 63047 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (63047) provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99053) provided on February 13, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code.

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. Code 99053 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 this code. 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 (99053) provided on February 13, 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 clinical information provided supports the need for care in an LTACH. You say that the enrollee needs more respiratory support than a skilled nursing home can provide. You say that an LTACH is the only appropriate discharge disposition at this time. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the services needed could be provided in another setting.

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 necessitating admission to a LTACH. 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 long term acute care hospital (LTACH) services.
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 enrollee currently meets IRF admission criteria under CMS guidelines. You say that the enrollee requires IRF care in order to facilitate increased independence and a return to her home and her community with an improved quality of life. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF care. The Plan says that the enrollee's needs can be met in an alternate level of care.

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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray exam of the shoulder (73030) provided on May 17, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the X-ray exam of the shoulder. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for the services rendered by an OON provider.

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 the X-ray exam of the shoulder (73030) provided on May 17, 2021, by an out-of-network (OON) provider.