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

We decided that the Plan does not have to pre-approve continuation of SNF services.

You asked the Plan to pre-approve continuation of SNF services. You say that you have only had five or six therapy sessions and you feel as though they are not enough. The Plan denied your request. The Plan says you no longer require daily skilled services.

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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network
(OON) provider.

You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide these services. Therefore, coverage criteria have not been met.

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
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70553).

You asked the Plan to pre-approve an MRI of the brain. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

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 an MRI of the brain. Our reviewer says that the services are medically necessary. Our physician reviewer found small lesions may be missed with a positron emission tomography (PET) and MRI is the most sensitive means with which to evaluate for brain lesions. In such cases, neurological deficits need not be present for metastatic disease to be present. Evaluation for brain metastases is crucial for treatment planning. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the brain have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the brain (70553).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services rendered from May 2, 2021 to June 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 the services are not covered.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records show that the services were not performed for a diagnosis of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the acupuncture services rendered from May 2, 2021 to June 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient visit (99215) provided on February 16, 2021.
You asked the Plan to pay for the evaluation and management service. You say that the appointment was not related to your hospice diagnosis. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. You ended Medicare Hospice benefits on February 10, 2021. The services in question were provided before the
end of that month. Therefore, we decided that the Plan does not have to pay for the outpatient visit (99215) provided on February 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 28, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records do not show that the specimen was collected in laboratory setting.
This means that the claim was billed with the incorrect POS code. 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 the lab services provided on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder genetic testing provided on April 6, 2021.
You asked the Plan to pay for the CxBladder genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were 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 pay for the CxBladder genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee has an evaluation of gross hematuria. Biopsies demonstrated urothelial carcinoma in situ. The documentation does not support that the testing will impact the management and outcome of this enrollee. Therefore, the enrollee did not meet criteria for the services rendered. 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 CxBladder genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder genetic testing provided on April 6, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) and nerve conduction studies (95908) provided on August 18, 2020.
You asked the Plan to pay for needle electromyography and nerve conduction studies. You say that the requested services were medically necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the records do 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 95886 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)." The CPT Code Manual definition of code 95908 is
"Nerve conduction studies; 3-4 studies." 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 needle electromyography and nerve conduction studies. Our reviewer says that the services at issue do not meet criteria for reimbursement consideration per the submitted documentation. Our reviewer found that the description for code 95886 includes nerve conduction studies; as there is no nerve conduction study documented, this procedure would not be covered. For code 95908, the technical report documents "Pedicle screw stimulation was performed with all stimulated responses above threshold values. The Surgeon was informed and acknowledged." Nerve conductions studies include measurements of amplitude, latency, and conduction velocity, which are not documented in technical report. Therefore, this procedure would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) and nerve conduction studies (95908) provided on August 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 7, 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 April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered on May 20, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.
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 $45 copayment for each in-network office visit to other providers that aren't your POC or primary care provider.
Review of the file shows that you received ophthalmology services on May 20, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the in-network office visit to other providers that aren't your POC or primary care provider 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 the physician services rendered on May 20, 2021.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the cardiac ultrasound to $250. We decided that the Plan does not have to waive the copayment for the cardiac ultrasound in full.
You asked the Plan to waive the copayment for the cardiac ultrasound. You say that had you known that you would have incurred this high of a copayment, you would have gone to a different location for this service. The Plan says that you were charged the $400 copayment for outpatient hospital services correctly.
We decided that the Plan has to reduce the copayment for the cardiac ultrasound.
Medicare rules require that Plans clearly and accurately disclose your cost sharing amounts in their Evidence of Coverage. In this case, your Evidence of Coverage clearly states that for members in the county where you reside, you pay a $250 copayment for outpatient diagnostic tests (including ultrasounds). There is no statement in the section of the Evidence of Coverage where this copayment is found that a different (and higher) copayment would apply if you were to receive this diagnostic test at an outpatient hospital facility. The Plan is inappropriately charging the copayment for outpatient hospital services, when they should be applying the copayment for outpatient diagnostic tests to the cardiac ultrasound you received. Therefore, we decided that the Plan has to reduce the copayment for the cardiac ultrasound you received to $250. However, we decided that the Plan does not have to waive the copayment for cardiac ultrasound in full.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 17, 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 services were 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 December 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87798, 87486, 87640, 87651, 87633)
provided on October 1, 2020.

You asked the Plan to pay for laboratory services. You say that this is supported by 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 laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (87798, 87486, 87640, 87651, 87633) provided on
October 1, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76705) provided on May 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 services (76705) provided on May 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2740) provided on June 4, 2021.

You asked the Plan to pay more for the crown. You say that you were initially told your cost for the services would be $120, but when you went to this appointment you were told your cost would be $572. You also say that you are on Medicare, a fixed income, and this was not your mistake. The Plan denied your request. The Plan says the cost share for this service was applied correctly.

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, you are responsible for a 50% coinsurance. Therefore, we decided that the Plan does not have to pay more for the crown (D2740) provided on June 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computer-assisted musculoskeletal surgical
navigational orthopedic procedure.

You asked the Plan to pre-approve a computer-assisted musculoskeletal surgical navigational orthopedic
procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical
necessity has not been established. Therefore, coverage criteria have not been met.

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 computer-assisted musculoskeletal
surgical navigational orthopedic procedure. Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found computer navigation
has not been shown to be more effective and have better outcomes than traditional open orthopaedic surgery. It
is not medically needed.

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 computer-assisted musculoskeletal surgical navigational orthopedic procedure
have not been met. Therefore, we decided that the Plan does not have to pre-approve a computer-assisted
musculoskeletal surgical navigational orthopedic procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle libre 14-day sensor kit.
You asked the Plan to pre-approve a Freestyle libre 14-day sensor kit. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle libre 14-day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle libre 14-day sensor kit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on April 9, 2021.
You asked the Plan to pay for physical therapy services. You say that the claim was denied incorrectly without appropriate review of the medical records. You say that the medical records should be thoroughly reviewed, and the claim reprocessed for necessary payment. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the billed services.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a physician assistant, which is a non-physician practitioner. As such, PT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on April 9, 2021.