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 the enrollee needs a plan to get home and needs SNF care in order to get better. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee's needs can safely be met in a lower level of care.  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 the enrollee does not have documented skilled nursing needs.  The enrollee does not have documented skilled therapy needs.  The enrollee is consistently ambulating more than 100 feet and tending to activities for daily living (ADLs) with minimal supervision.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs, as a practical matter, can be provided 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 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 the psychotherapy rendered on June 21, 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 must follow Medicare rules. The rules say that a clinical psychologist must have a referral and consult from the beneficiary's primary care physician.  We looked at the file and Medicare rules. There is no documentation of a referral and consult from the beneficiary's primary care physician. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy rendered on June 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a positioning cushion/pillow/wedge (E0190) provided on October 21, 2021.  You asked the Plan to pay for a positioning cushion/pillow/wedge. You say that the item at issue is a medical necessity for your condition. The Plan denied your request. The Plan says the item at issue is not a covered benefit.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a positioning cushion/pillow/wedge (E0190) provided on October 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a wheelchair power seat elevation system, an electronic connection, an expandable controller, and an access harness.  You asked the Plan to pre-approve a wheelchair power seat elevation system, an electronic connection, an expandable controller, and an access harness. You say that the enrollee meets the criteria for coverage. The Plan denied your request. The Plan says the items which remain in dispute are not medically necessary.  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 a wheelchair power seat elevation system, an electronic connection, an expandable controller, and an access harness. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices. The enrollee does not require a separate display, other electronic devices, or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wheelchair power seat elevation system, an electronic connection, an expandable controller, and an access harness have not been met. Therefore, we decided that the Plan does not have to pre-approve a wheelchair power seat elevation system, an electronic connection, an expandable controller, and an access harness.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) therapeutic, prophylactic, or diagnostic injection (specify substance or drug (96372) neuromuscular reeducation (97112) unclassified drugs (J3490) thiamine injection (J3411) pyridoxine injection (J3415) compounded drug, not otherwise classified (J7999) vasopneumatic device (97016) provided August 11, 2021  You asked the Plan to pay for the outpatient services. You say that please review the documents and reprocess this claim for payment. The Plan denied your request. The Plan says these services re not covered benefits.  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. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) therapeutic, prophylactic, or diagnostic injection (specify substance or drug (96372) neuromuscular reeducation (97112) unclassified drugs (J3490) thiamine injection (J3411) pyridoxine injection (J3415) compounded drug, not otherwise classified (J7999) vasopneumatic device (97016) provided August 11, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a podiatry visit provided on March 17, 2021.  You asked the Plan to waive the copayment for the podiatry visit. You say that the provider advised you that you needed to pay the bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35 copayment for each podiatry visit.     You have been asked to pay a $35 copayment for the podiatry visit. Podiatry visits fall within the Podiatry Services 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 a podiatry visit provided on March 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on May 7, 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.      We looked at the file and Medicare rules. 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 drug testing rendered on May 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (72129) provided on July 23, 2021.  You asked the Plan to pay for code 72129. 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 supported.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two separate CT scans (72129) were provided on July 23, 2021 by this provider. The file shows that the Plan paid for one claim submitted with code 72129 by this provider. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan (72129) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on April 15, 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 separately payable.  The Plan must follow Medicare rules. The rules say that modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service.    We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was incorrectly billed with modifier -25, as the visit was not separate from the billed osteopathic manipulation services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit rendered on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for epidural injections provided on May 26, 2021, at an outpatient hospital.  You asked the Plan to waive the copayment for epidural injections. You say that you did not have any surgery and should not be charged the copayment for surgery. The Plan denied your request. The Plan says the correct copayment was applied.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for each Medicare-covered outpatient surgery service at an outpatient hospital.   You have been asked to pay a $300 copayment for epidural injections. Epidural injections fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 epidural injections provided on May 26, 2021, at an outpatient hospital.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on September 14, 2021.  You asked the Plan to pay for the comprehensive exam. You say that this service was necessary, as you wanted a second opinion before having your tooth extracted. The Plan denied your request. The Plan says comprehensive oral exams may only be covered once every three plan years. You had a previous comprehensive exam in October 2019. Therefore, the exam in question exceeds the frequency limitation of your 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. The Plan can cover one comprehensive exam (D0150) every three plan years.   Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive exam is requested in a frequency that is not covered under this benefit. Documentation shows that the Plan covered this service for you less than three years ago. Therefore, we decided that the Plan does not have to pay for the comprehensive oral exam (D0150) provided on September 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional bone density study coded as 77080 provided on July 22, 2021.  You asked the Plan to pay for the bone density study. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been billed according to Medicare guidelines.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 77080 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the bone density study have not been met. Therefore, we decided that the Plan does not have to pay for an additional bone density study coded as 77080 provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the clinical crown lengthening - hard tissue (D4249) provided September 29, 2021.  You asked the Plan to pay for the clinical crown lengthening. You say that the Plan did not inform you that this service would not be covered. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 clinical crown lengthening - hard tissue (D4249) provided September 29, 2021.  Your complaint about issue with the Plan potentially providing misinformation or a lack of timely information 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services 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 procedure code 36012 is not supported.  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 36012 is selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus).  We find that CPT code 36012 is not supported in the medical record. Specifically, there is no documentation of selective catheter placement in the venous system. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on April 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (74018) provided July 11, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is 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 74018 shares a bundled relationship with code 74250. 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 radiology services (74018) provided July 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on August 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment and you did not know that the facility failed to get preauthorization for this patient, so you treated this patient anyway. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. 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 a domiciliary or rest home visit (99336) provided on August 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided June 28, 2021 to July 30, 2021.  You asked the Plan to pay for the chiropractic services. You say that you are requesting payment for the indicated service dates. The Plan denied your request. The Plan says this service is not a covered benefit.  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.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided June 28, 2021 to July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient admission.  You asked the Plan to pre-approve the inpatient admission. You say that the provider said you need to be monitored for 24 hours after the procedure. The Plan denied your request. The Plan says there is no documentation provided to support the expectation that you will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.      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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you are undergoing a planned transurethral electrosurgical resection of prostate (TURP). You are medically stable and have been provided medical clearance to undergo this elective procedure. Our reviewer found that the planned procedure listed under current procedural terminology (CPT) code 52601 is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The procedure is currently approved as an ambulatory procedure. Our physician reviewer also found that there is no documentation provided to support the expectation that you will require a greater than 2 midnight stay.  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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission.
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 appears to be improving overall and only requires short-term additional acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment is complete.    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.