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

We decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation (D0140), extraction (D7210), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on April 20, 2021.
You asked the Plan to reimburse an additional amount for the limited oral evaluation and extraction. You say that you had to have an emergency tooth extraction. You say that you needed anesthesia as you suffer from severe anxiety. You say that you were not able to find an in network provider in a range that you were comfortable driving to. You also say that the services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that out of network providers are paid
according to a maximum allowable fee schedule. The Plan also says out of network providers may bill you for any amount greater than what the plan pays.
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, out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to reimburse an additional amount for the limited oral evaluation (D0140), extraction (D7210), the initial 15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223) provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 10, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is 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, molecular genetic hereditary predictive screening, 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 rendered on April 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF stay.
You asked the Plan to pre-approve the SNF stay. You say that you have lost most of your vision and are a fall
risk. You also say that you would have no one at home to assist you. The Plan denied your request. The Plan
says the SNF services you are requesting do not meet the requirements for approval.
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 the SNF stay. Our reviewer says that
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill,
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do 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. Although you have skilled therapy needs,
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of
the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF
stay.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided on August 6, 2019, through August 31, 2019.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the Resource Utilization Groups scores of RUB111X14 and RUB20X12.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. 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 SNF services. Our reviewer says that the documentation reviewed does not meet criteria for coverage consideration. Our reviewer found the documentation did not include the Minimum Data Set which includes a comprehensive standardized assessment of each resident's functional capabilities and health needs to support the need for skilled nursing services. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided on August 6, 2019, through August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid check you received on April 28, 2021.
You asked the Plan to pay for the hearing aid check. The Plan denied your request. The Plan says this is not a
covered benefit.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids and routine hearing exams.
We looked at the file and the Plan's rules. The hearing aid check in this case was provided to replace a lost
hearing aid. This was not a routine hearing exam. The Plan does not cover costs associated with hearing aid
loss. Based on this information, we decided that the Plan's rules for coverage of the hearing aid check have not
been met. Therefore, we decided that the Plan does not have to pay for the hearing aid check you received on
April 28, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF stay.
You asked the Plan to pre-approve the SNF stay. You say that you are a fall risk, are unable to regain strength, and cannot help yourself. You also say that you have had therapy, but nothing is helping you. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements for approval.
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 the SNF stay. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do 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. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill that includes transportation for non-medical needs, and home assistance (repairs) (S9986).
You asked the Plan to pre-approve Special Supplemental Benefits for the Chronically Ill that includes transportation for non-medical needs, and home assistance (repairs). You say that you want the Plan to cover these services. The Plan denied your request. The Plan says you do not meet the requirements for the Special Supplemental Benefit for Chronic Diseases.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Special Supplemental Benefits for the Chronically Ill that includes transportation for non-medical needs, and home assistance (repairs) have not been met. Specifically, we have confirmed that you do not have
one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill that includes transportation for non-medical needs, and home assistance (repairs) (S9986).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), the prophylaxis (D1110), and the periodic oral evaluation (D0120) received June 6, 2020 from the out-of-network provider.
You asked the Plan to pay for the dental services. You say that the requested services should be covered by the Plan. The Plan denied your request. The Plan says the provider was not in-network on the date of service.
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 eligible for coverage under this benefit. Services are only covered when you use providers that are in the Plan's network. The provider was not in the Plan's network on the date of service. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), the prophylaxis (D1110), and the periodic oral evaluation (D0120) received June 6, 2020 from the out-of-network provider.
Your complaint about the provider submitting paperwork to join the Plan's network is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from February 1, 2021, to February 24, 2021.
You asked the Plan to pay for the home health services. You say that you have a contract with the Plan which allows you to bill per visit, and you have always been paid when billing this way in the past. The Plan denied your request. The Plan says this claim was submitted for a Medicare patient and was not billed with a correct TOB.
The Plan must follow Medicare rules. Medicare rules say that valid TOBs for home health services include 0322, 0327, 0328, 0329, and for certain services 034X. The TOB submitted for this claim is 0323 which is not a valid TOB for a Medicare home health claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from February 1, 2021, to February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tresiba Flex (J3590).

You asked the Plan to pre-approve Tresiba Flex. You say that Tresiba is the most appropriate insulin for the enrollee, with more consistent absorption and with the best possibility for consistent dosing. The Plan denied your request. The Plan says Tresiba Flex is self-administered and is not covered under Medicare 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 Tresiba Flex (J3590).

Benefits for Tresiba Flex 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing provided on January 25, 2021.

You asked the Plan to pay for genetic testing. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because there is no documentation that the enrollee is being considered for repeat biopsy.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing may be covered for males with previous negative biopsy who are being considered for repeat biopsy. 

We looked at the file and Medicare rules. The record does not show that the enrollee was being considered for repeat biopsy at the time this testing was ordered. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on April 14, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the diagnosis codes are not covered.

The Plan must follow Medicare rules. The rules say that all ICD-10 diagnosis codes not listed under the "ICD-
10 Codes that Support Medical Necessity" section of this article do not support medical necessity for code
G0483.

We looked at the file and Medicare rules. Billed procedure code G0483 (definitive drug testing, 22+ classes)
was not billed with an ICD-10 diagnosis code that supports medical necessity. Therefore, we decided that the
Plan does not have to pay for the definitive drug testing rendered on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2021 by a non-participating provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating 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 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 laboratory services provided on March 9, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 13, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. 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, a cardiovascular risk assessment panel, 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 rendered on February 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second medical opinion to be provided by an out-of-network (OON) ophthalmologist.

You asked the Plan to pre-approve a second opinion from an OON provider. You say that you have had three unsuccessful eye surgeries and will need a fourth. You would like a second opinion from a provider that is not in the Plan's network. The Plan denied your request. The Plan says while a second opinion may be considered reasonable and necessary, you are required to use network providers for medical care and services when they are available. These services are not urgent or emergent in nature and can be received from another in-network provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second medical opinion to be provided by an out-of-network (OON) ophthalmologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid testing coded
87633 provided on March 2, 2021.

You asked the Plan to pay for the infectious agent detection by nucleic acid testing. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed
incorrectly.

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 87633 is infectious agent detection by nucleic acid (DNA
or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza
virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and
multiplex amplified probe technique, multiple types or subtypes, 12-25 targets.

We find that CPT code 87633 is not supported in the medical record. Specifically, the documentation shows
that a Multiplex polymerase chain reaction (PCR) respiratory viral panels of 6 or more pathogens was
performed. Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. Based on this
information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid
testing have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent
detection by nucleic acid testing coded 87633 provided on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says an admission to an IRF was denied as not meeting criteria, not medically necessary, and a lower level of care might be appropriate.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that 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 the acute IRF admission and services.