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

 We decided that the Plan does not have to pre-approve 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 the services you require such as intermittent therapy and outpatient hemodialysis can safely be received at a different 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for 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 skilled nursing facility (SNF) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit for psychotherapy (90833, 99204) provided on September 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit for psychotherapy. You say that you were told by the Plan that all services by this provider would be covered because your primary care physician (PCP) referred you. You also say that you were told the PCP sent a copy of that referral to the Plan as well, and you need to see this person for psychiatric medication at least once a month. You also say that your PCP will not prescribe these medications. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 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 an office visit for psychotherapy (90833, 99204) provided on September 14, 2021, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 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. Your rehab needs can be safely
met in an alternate and lower intensity setting such as in a skilled nursing facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy services coded 29822 provided on
July 10, 2020.
You asked the Plan to pay for the shoulder arthroscopy services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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 29822
is a column II code to column I code 29827. 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 shoulder arthroscopy services coded 29822 provided on July
10, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.
  
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 1, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria.

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, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 6, 2021, to April 2, 2021.
You asked the Plan to pay for the home health services. You say that RAP claims do not require payment as of January 1, 2021. You also say that this claim was billed correctly. The Plan denied your request. The Plan says the non-contracted provider submitted the final claim on April 4, 2021 for the home health care period which started on March 6, 2021, and ended on April 2, 2021. The Plan also says that the deadline for submission of the final claim was within 5 days after the from date of March 6, 2021.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the record indicates the RAP was not submitted within 5 days of the from the start of care date, March 6, 2021. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 6, 2021, to April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on July 30, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that the Guardant360 testing provided on
July 30, 2021, was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet
criteria for the Guardant360 testing provided on July 30, 2021.
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 Guardant360 testing. Our reviewer says
that the enrollee did not meet criteria for the Guardant360 testing provided on July 30, 2021. Our physician
reviewer found the enrollee is with a diagnosis of non-small cell lung cancer. It is documented that the enrollee
had previously undergone Guardant Next Generation Sequencing (NGS) on October 14, 2020. LCA A58192
provides coverage for Guardant360 testing for those patients who have not previously been tested with the
GUARDANT360 test for the same primary cancer. For a patient who has been tested previously using
GUARDANT360 for a cancer, that patient may only be tested again when the patient has a new primary cancer
diagnosis. The documentation does not support that the enrollee in this case has a new primary cancer
diagnosis.
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 Guardant360 testing have not been met. Therefore, we decided that the Plan
does not have to pay for the Guardant360 testing provided on July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 the enrollee is improving but still has a leukocytosis and requires acute care services.
The enrollee continues to receive acute care services, and these have not been denied. The medical record does
not indicate that the enrollee requires services that she is not currently receiving but that would be available at
the LTACH facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 19, 2021 by an out-of-
network (OON) provider.
You asked the Plan to pay for the drug testing. 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.
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 drug testing provided on July 19, 2021 by an
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and panoramic x-ray (D0330) provided on August 18, 2021.  You asked the Plan to pay for the dental services. You say that your dental office closed. You say that their calls were forward to another local dental office. You say that the new office had no openings and would not forward your records. You also say that you were not at fault for these charges. The Plan denied your request. The Plan says comprehensive oral evaluation is covered once every 3 years. The Plan says that 1 panoramic or complete series x-ray is covered every 5 years. The Plan also says that the frequency limits have been exceeded.  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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on January 8, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and panoramic x-ray (D0330) provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services (69990, 22612, 63047, 20936, and 20930) provided on December 8, 2020.  You asked the Plan to pay for codes 69990, 22612, 63047, 20936, and 20930. 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 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. In this case, we have confirmed that codes 69990, 22612, and 63047 are column II codes to column I code 22633. This claim has not been billed with an appropriate modifier to bypass the edit.   Codes 20936 and 20930 have a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to. 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 surgical services (69990, 22612, 63047, 20936, and 20930) provided on December 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2335) on tooth #24 provided on
October 18, 2021.
You asked the Plan to pay for the resin-based composite. You say that you would like to appeal this service.
The Plan denied your request. The Plan says this service 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, resin-based composite (D2335) is
limited to 1 per floating 36 months, when rendered on the same tooth. The record shows that you received a
resin-based composite (D2335) on tooth #24 on December 8, 2020, and your resin-based composite (D2335)
benefit for tooth #24 has been exhausted. Therefore, we decided that the Plan does not have to pay for the
resin-based composite (D2335) on tooth #24 provided on October 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640) provided August 1, 2020.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 are not supported in the medical record. Specifically, the place of service listed on the claim (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87496, 87498, 87631, 87798, 87486, 87541, 87581, 87640) provided August 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for office visits provided from August 13, 2021, to September 2, 2021.  You asked the Plan to waive the copayment for office visits. You say that you disagree with the charges because you were switched to a new plan and now have a lot of charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $10 copayment for primary care provider visits and a $45 copayment for specialist visits.   You had a primary care provider visit on August 13, 2021. Therefore, you are responsible to pay the $10 copayment.   You had a specialist visit on September 2, 2021. Therefore, you are responsible to pay the $45 copayment.  The total amount you owe is: $55.   You have been asked to pay the total copayment amount of $55 for office visits. Office visits fall within the physician/practitioner services, including doctor's office visits 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 copayment for office visits provided from August 13, 2021, to September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services provided on August 3, 2021.
  
You asked the Plan to pay for psychotherapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 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 psychotherapy services provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services received on February 3, 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 codes must include route of administration modifiers.
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 the denied codes is: CPT 80053: Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 13, 
2021, to May 16, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you had a life threatening 
emergency due to the coronavirus. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount.

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 $335 
copayment for days 1-6 for inpatient hospital care. 

You received inpatient hospital care from May 13, 2021, to May 16, 2021. Therefore, you are responsible to 
pay a $335 copayment for days 1-3 (May 13, 2021, to May 15, 2021). The total amount you owe is: $335 
(copayment) x 3 (inpatient days) = $1,005
. 
You have been asked to pay the total copayment amount of $1,005 for inpatient hospital care. Inpatient hospital 
care falls within the inpatient hospital care 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 copayment for inpatient hospital care provided on May 13, 2021, to May 
16, 2021.