Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home health services you received from July 4, 2021, to July 14, 2021.

You asked the Plan to waive the coinsurance for the home health services. You say that these charges are excessive. The Plan denied your request. The Plan says you were charged 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 15% coinsurance for home health services. 

You have been asked to pay 15% coinsurance for the home health services. 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 home health services you received from July 4, 2021, to July 14, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the infectious agent detection by nucleic acid provided on October 21, 2020, billed with code 87799.

You asked the Plan to pay for the services billed as 87799. You say that medical records have been submitted to support medical necessity. The Plan denied your request. The Plan says that this was denied as experimental. The Plan was not able to perform an appeal review of this decision within the timeframe and was required to forward the case for independent review.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided sufficient documentation to determine whether the denial of this service is supported. A copy of the claim has not been provided in order to ascertain the infectious agents being represented by this code. Payment was made for the testing for the cytomegalovirus. Without additional information, it cannot be determined that the denial as experimental is justified. Therefore, we decided that the Plan has to pay for the infectious agent detection by nucleic acid provided on October 21, 2020, billed with code 87799.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215), the annual alcohol misuse screening (G0442), the annual, face-to-face intensive behavioral therapy for cardiovascular disease (G0446), the face-to-face behavioral counseling for obesity (G0447), the annual depression screening (G0444), and the urinalysis (81002) rendered by the out-of-network (OON) provider on May 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 office visit (99215), the annual alcohol misuse screening (G0442), the annual, face-to-face intensive behavioral therapy for cardiovascular disease (G0446), the face-to-face behavioral counseling for obesity (G0447), the annual depression screening (G0444), and the urinalysis (81002) rendered by the out-of-network (OON) provider on May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve torus mandibularis removal (D7473) provided by a participating provider.

You asked the Plan to pre-approve torus mandibularis removal. You say that you need this done so you can get dentures. The Plan denied your request. The Plan says D7473 is not a covered benefit.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve torus mandibularis removal (D7473) provided by a participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed, total electric (head, foot and height 
adjustments), with any type side rails, with mattress (CPT code E0265), mattress cover (CPT code E1399), and 
sheet set (CPT code E1399) purchased on June 18, 2021.

You asked the Plan to pay for the items. You say that you are appealing for reconsideration of the denied 
charges. The Plan denied your request. The Plan says the items are not covered by Medicare or the health plan.

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 items have not been met. The rules say that a total electric 
hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience 
feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided that the Plan 
does not have to pay for the hospital bed, total electric (head, foot and height adjustments), with any type side 
rails, with mattress (CPT code E0265), mattress cover (CPT code E1399), and sheet set (CPT code E1399) 
purchased on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81226, 81225, 81241, 81240, 
81350, 81232, 81256, 81291, 81227, 81230, 81355, 81283, 81231, 81328, 81335, 81381, 81220, and 81247 
provided on July 28, 2020.

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 are not payable as 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.

We find that CPT codes 81226, 81225, 81241, 81240, 81350, 81232, 81256, 81291, 81227, 81230, 81355, 
81283, 81231, 81328, 81335, 81381, 81220, and 81247 are not supported in the medical record. Specifically, 
the documentation shows that molecular pharmacogenetic testing was completed. When a laboratory assays 
two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. 

A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Review of 
the file shows that more than one code was billed for the services provided. This means these services were 
billed incorrectly. 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 81226, 81225, 81241, 81240, 81350, 81232, 81256, 81291, 81227, 81230, 81355, 81283, 81231, 81328, 
81335, 81381, 81220, and 81247 provided on July 28, 2020.
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 requires an IRF admission. The Plan 
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that on review of the available records the enrollee is stable and does not meet CMS 
coverage criteria for an IRF admission. With his current medical stability, and no other acute medical 
complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week 
(at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical 
conditions. The enrollee has no acute rehab nursing needs noted in the record. At the current functional level, 
the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days 
per week with multidisciplinary approach to daily therapy at the time he was admitted to IRF. He will not 
tolerate and benefit from an IRF intensity with current poor activity tolerance. IRF admission is not medically 
necessary based on lack of medical complexity and poor activity tolerance. The documentation does not 
support the necessity for admission to an IRF. While the enrollee may benefit from continued physical therapy, 
and occupational therapy, his rehabilitation needs can be safely provided in an alternate and low intensity 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services provided on August 9, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for dental services. You say that these services were medically necessary. You say that you were referred. The Plan denied your request. The Plan says there are in-network providers available who could have provided these services.
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 dental services provided on August 9, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual psychotherapy services (90837) provided March 11, 2021 to July 9, 2021.

You asked the Plan to pay for the psychotherapy services. You say that prior to setting up an appointment, you contacted the Plan to get approval. You were approved by the Plan and was told that your copay was $40. The Plan denied your request. The Plan says the rendering provider is a licensed professional counselor. A licensed professional counselor is not a Medicare qualified mental health care professional.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for integrated biopsychosocial assessment (90791) individual psychotherapy services (90837) provided March 11, 2021 to July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).

You asked the Plan to pre-approve an automatic blood pressure monitor. You say that your doctor has said that the requested item is something you need and you should be able to get it. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (A4670).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sildenafil.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Sildenafil.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee on September 3, 2020.

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 records do not validate a physician diagnosis of malnutrition.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 

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 enrollee was hospitalized from 9/1/2020 through 9/3/2020 for evaluation of frequent falls and ambulatory dysfunction. The enrollee was subsequently transferred to a skilled nursing facility. A dietitian noted nutritional problems, with inadequate oral intake. The enrollee's BMI is documented to be 19.3 which corresponds with a normal weight. The enrollee was on a regular diet with Ensure Plus two times per day for malnutrition, with a start date of 9/4/2020 and an end date of 9/8/2020, noted on the Order Recap Report. The available medical records in the case file do not support the coding of parenteral/IV feeding, or a physician diagnosis of malnutrition. 

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 skilled nursing facility (SNF) services provided to the enrollee on September 3, 2020.
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 this is not medically necessary.

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 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 he 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: 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 inpatient acute care and is not currently stable for transfer to an 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 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 he 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wound therapy pump and supplies you received from June 28, 2021, to July 27, 2021.

You asked the Plan to waive the coinsurance for the wound therapy pump and supplies. You say that this item has been returned. You say that you neither wanted nor used this item. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that they contacted the provider and you did not return this item until August 18, 2021. The provider also confirmed that you used this item for two weeks, so the coinsurance was correctly 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 20% coinsurance for durable medical equipment and supplies.

You have been asked to pay 20% coinsurance for the wound therapy pump and supplies. The wound therapy pump and supplies falls within the durable medical equipment and supplies 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 wound therapy pump and supplies you received from June 28, 2021, to July 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) home occupational therapy visits (G01052).

You asked the Plan to pre-approve home occupational therapy visits. You say that the requested home 
occupational therapy visits are medically necessary. The Plan denied your request. The Plan says the home 
occupational therapy visits do not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy.

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 home occupational therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found the enrollee and staff have been instructed in a home 
exercise program. The enrollee remains maximal assist for all activities of living except for feeding self, is 
unable to follow 1-step commands consistently, and receives 24-hour care. The requested services are not part 
of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required 
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home occupational therapy visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve nine (9) home occupational therapy visits (G01052).