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

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 5, 2021 to May 25, 2021.

You asked the Plan to pay for the SNF services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee's care needs, as a practical matter, could be provided at a lower level of care (ex. long term care (LTC)). 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 5, 2021 to May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve blood work/lab testing.  You asked the Plan to pre-approve the testing. You say that you feel like you've been exposed to mold. The Plan denied your request. The Plan says the order must be requested by the treating physician.  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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no objective findings on examination or other information in the history is suggestive of any type of mold or other fungal toxicity or infection to support this test. Therefore, you do not need this testing.  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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve blood work/lab testing.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the observation care discharge day management coded 99217 provided on June 7, 2021.  You asked the Plan to pay for the observation care discharge day management. 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.  In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).  We find that CPT code 99217 is not supported in the medical record. Specifically, the qualifying initial (99218-99220) or subsequent observation care (99224-99226) was not found in the documentation. This means this code is not payable. Based on this information, we decided that Medicare rules for coverage of the observation care discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for the observation care discharge day management coded 99217 provided on June 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 18, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on May 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee arthroscopy coded 29875 provided on March 30, 2021.  You asked the Plan to pay for the knee arthroscopy. 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.  In this case, the CPT Code Manual definition of code 29875 is arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure).    We find that CPT code 29875 is not supported in the medical record. Specifically, the operative report did not include documentation of a limited surgical Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the knee arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for the knee arthroscopy coded 29875 provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional acupuncture services.  You asked the Plan to pre-approve additional acupuncture services. You say that this is medically necessary. The Plan denied your request. The Plan says your request exceeds the benefit limit.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met.  Specifically, the file shows that you have already had more than 20 visits in this calendar year. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed (37225) and the moderate sedation services (99152) rendered by the out-of-network (OON) provider on June 18, 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 revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed (37225) and the moderate sedation services (99152) rendered by the out-of-network (OON) provider on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the P-STIM posterior auricular stimulator.  You asked the Plan to pre-approve the P-STIM posterior auricular stimulator. You say that you would like reconsideration because the requested device is medically necessary. The Plan denied your request. The Plan says this device is considered experimental.  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 the P-STIM posterior auricular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental and investigational.  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 P-STIM posterior auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve the P-STIM posterior auricular stimulator.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 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 these services are not authorized because screening testing is not a Medicare benefit.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation did not clearly describe the enrollee having an abnormal or unexpected result from a urine drug screen to justify definitive drug testing which is only supported in this clinical situation and only a focused test for a specific drug family related to the abnormal result. Therefore, without sufficient support for this request, the definitive drug testing will be considered not medically necessary.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 28, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (88305, 88313, 88314, 88346, 88348, 88350) rendered by the out-of-network (OON) provider on May 28, 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 laboratory services (88305, 88313, 88314, 88346, 88348, 88350) rendered by the out-of-network (OON) provider on May 28, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 14, 2021, to July 13, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the SNF care is not medically necessary.  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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the SNF care have not been met. Specifically, the enrollee did not receive skilled care during their stay. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from June 14, 2021, to July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee arthroscopy coded 29874 provided on December 7, 2020.  You asked the Plan to pay for the knee arthroscopy. 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 separately 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, we have confirmed that code 29874 for the knee arthroscopy is a column II code to column I code 29880. 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 knee arthroscopy coded 29874 provided on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) and a lumbar-sacral orthosis (L0650) provided on December 29, 2020.  You asked the Plan to pay for a shoulder elbow wrist hand orthosis and a lumbar-sacral orthosis. You say that this is supported in the records. The Plan denied your request. The Plan says required documentation has not been submitted.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery for the supplies provided in this case. There is not an itemized shipping invoice in the file. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a shoulder elbow wrist hand orthosis (L3960) and a lumbar-sacral orthosis (L0650) provided on December 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a bone replacement graft (D7953), an extraction (D7210), and a surgical placement of implant (D6010) provided on April 20, 2021.  You asked the Plan to pay for a bone replacement graft, an extraction, and a surgical placement of implant. You say that the services were necessary and should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a bone replacement graft (D7953), an extraction (D7210), and a surgical placement of implant (D6010) provided on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for 2 x-rays of the lower leg (bilateral; 73590) and 2 x-rays of the foot (bilateral; 73630) provided by an in-network provider on June 23, 2021.  You asked the Plan to waive the copayment for lower leg and foot x-rays. You say that you do not agree with the multiple copayments applied to the x-rays you received. You also say that you paid $15 and later received a bill for $45. You don't think it's fair to be charged for each x-ray. The Plan denied your request. The Plan says the copayment was applied correctly, in accordance with your Plan contract. The Plan states the copayment applies to each Medicare-covered standard x-ray until you meet your maximum out-of-pocket.    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 $15 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.   You have been asked to pay a $60 copayment for lower leg and foot x-rays ($15 for each x-ray x 4 total x-rays = $60). X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. As reported by the claim, at the time of service, you had not yet met your in-network maximum out-of-pocket. 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 2 x-rays of the lower leg (bilateral; 73590) and 2 x-rays of the foot (bilateral; 73630) provided by an in-network provider on June 23, 2021.   Your complaint insisting you should be told ahead of time what the bills are going to amount to 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. You are responsible for understanding your contractual obligations with the Plan.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transportation services (A0428, A0425) provided on April 12, 2021.  You asked the Plan to pay for the ambulance services. You say that this service was not related to hospice care and should be covered by the Plan. The Plan denied your request. The Plan says that the enrollee was enrolled in hospice from April 12, 2021, to April 21, 2021. In accordance with Medicare guidelines, the provider needs to bill Original Medicare for all services rendered on April 12, 2021. Per regulations, the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.  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 the ambulance transportation services (A0428, A0425) provided on April 12, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health skilled nursing services.

You asked the Plan to pre-approve additional home health skilled nursing services. You say that the enrollee is unable to administer insulin by herself and needs assistance. The Plan denied your request. The Plan says there is no supporting documentation for the need for twice a day skilled nursing services.

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 additional home health skilled nursing services. Our reviewer says that additional home health skilled nursing services are not medically necessary or reasonable. Our physician reviewer found that based on the documentation provided, the health Plan's denial should be upheld. The enrollee is a diabetic, who has demonstrated the ability to use her glucometer and administer insulin. The enrollee lives with family. While intermittent monitoring by a skilled nurse is reasonable, multiple daily visits are not. The requested frequency of visits is not medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health skilled nursing services.