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

We decided that the Plan does not have to waive the copayment for the ultrasound of a joint or other non-vascular
extremity structure (76882) provided on May 6, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that you feel this service was necessary
as a result of the COVID vaccine. The Plan denied your request. The Plan says this claim was processed
correctly, and your cost-sharing was assessed in accordance with your contract. The Plan also says that records
indicate that this ultrasound was performed to evaluate prominent lymph nodes noted on a scan provided earlier
in the year.

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 $60
copayment for Medicare-covered x-rays and ultrasounds.

You have been asked to pay a $60 copayment for the ultrasound. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for the ultrasound of a joint or other non-vascular extremity structure (76882) provided on May 6,
2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional OT visits.

You asked the Plan to pre-approve ten (10) additional OT visits. You say that additional OT is medically necessary. The Plan denied your request. The Plan says additional OT is not medically necessary.

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 ten (10) additional OT 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 that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. 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 ten (10) additional OT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional OT visits.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for skilled nursing facility (SNF) care provided on February 1, 2021, to February 4, 2021.

You asked the Plan to waive the copayment for SNF care. You say that the enrollee tested positive for Coronavirus and was hospitalized for several weeks. The enrollee was discharged to go home but two weeks later suffered a stroke which the doctor's say was caused by the side effects from Coronavirus. You also say that you are requesting reconsideration for the cost share. The Plan denied your request. The Plan says that the copayment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a $0 copayment per day, for days 1 to 20 for SNF care.

The Plan says the enrollee must pay a $184 copayment per day for SNF care. Based on the plan contract, however, the enrollee cannot be asked to pay more than $0 for SNF care. Additionally, the Plan has failed to forward any evidence to support that the member was previously in a Skilled Nursing Facility or that they had exhausted their 21-day benefit limit. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive the copayment for skilled nursing facility (SNF) care provided on February 1, 2021, to February 4, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.

You asked the Plan to pre-approve custom foot orthotics. You say that you need the requested items for treatment of your osteoarthritis. The Plan denied your request. The Plan says the requested custom foot inserts are not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.

Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99203 and 94981) provided n April 20, 2021.

You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because these services are being paid to the provider and not the group. The Plan denied your request. The Plan says these claims have processed correctly.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

We looked at your request, the file and Medicare rules. Based on this information we decide that Medicare rules for coverage of the chiropractic services have not been met. Specifically, the Plan only covers manual manipulation of the spine to correct subluxation. For this reason, CPT code 99203 is not covered. Additionally, CPT code 98941 was not billed with the required modifier to indicate that the services rendered were active treatment. Therefore, we decided that the Plan does not have to pay for chiropractic services (99203 and 94981) provided n April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement (D4355), gingival irrigation
(D4921) and the drugs dispensed in the office for home use (D9630) provided on January 13, 2021.

You asked the Plan to pay for the dental services. You say that you were not told you would owe money for
this care and feel this bill is expensive. The Plan denied your request. The Plan says these services are not
covered by your dental 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 pay for the full
mouth debridement (D4355), gingival irrigation (D4921) and the drugs dispensed in the office for home use
(D9630) provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on February 20, 2020.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on February 20, 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (25609) provided April 2, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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, the CPT Code Manual definition of code 25609 is Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments. 

We find that CPT code 25609 is not supported in the medical record. Specifically, the operative report does not detail the repair of 3 or more fragments.

Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (25609) provided April 2, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services represented by code 76705 provided
on April 26, 2021.

You asked the Plan to pay for code 76705. 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 code 76705
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. 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 ultrasound services represented by code 76705 provided on April 26,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the individual psychotherapy services (90832) provided on May 21, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychotherapy services. You say that please review and process the claim towards payment. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician. Enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent 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 the individual psychotherapy services (90832) provided on May 21, 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 you believe the IRF admission should be covered. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet the requirements for an IRF admission.

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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation for upcoming appointments. The Plan denied your request. The Plan says you have already used the allotted 24 one-way trips.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transport services (R0070) provided to the enrollee on April 8, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service was inappropriate.

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 R0070 is "Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen." 

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 place of service (POS) code reported is 31, which is for a Part A covered skilled nursing facility (SNF) stay. In this case, the plan provided evidence that the enrollee was receiving outpatient therapy at the skilled nursing facility. Since POS 31 is incorrect for a patient in a non-covered stay, the code is not supported. 

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 x-ray transport services (R0070) provided to the enrollee on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift (E1399) provided March 18, 2021.

You asked the Plan to pay for a stair lift. You say that the lift was medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair lift (E1399) provided March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography of the abdomen and pelvis (74178) provided on April 15, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $200 for each type of Medicare-covered diagnostic radiology service including magnetic resonance imaging (MRI), computed tomography (CT) scans, Nuclear Scans and positron emission tomography (PET) scans, per date of service. 

You have been asked to pay $193.12 for the Medicare-covered diagnostic radiology service provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment. You have issued payment to the provider in the amount of $80. The provider has adjusted the balance due for this service and you have been billed in the amount of $113.12. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography of the abdomen and pelvis (74178) provided on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotic.

You asked the Plan to pre-approve foot orthotics. You say that the enrollee is experiencing plantar heel pain. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Corus Coronary Artery Disease (CAD) Assay (81493)
provided on July 27, 2020.

You asked the Plan to pay for the Corus CAD Assay. 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 items and services that are not medically
necessary are not covered.

We looked at the file and Medicare rules. This contractor is rescinding coverage for the Corus CAD test. The
vendor has provided no evidence that use of the test results in improved patient outcomes (clinical utility).
Thus, this test does not meet Medicare's reasonable and necessary criteria for coverage. Therefore, we decided
that the Plan does not have to pay for the Corus Coronary Artery Disease (CAD) Assay (81493) provided on
July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81295, 81298, 81407, 81408) provided June 28, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that Coverage of Comprehensive Genomic Profile (CGP) is limited to one test per specimen and precludes the use of any other molecular testing on the specimen. Providers should not bill multiple unbundled codes.

We looked at the file and Medicare rules. The genetic testing panel was billed using multiple unbundled codes. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81295, 81298, 81407, 81408) provided June 28, 2020.