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

We decided that the Plan does not have to pre-approve the excision inferior turbinate (30130), fracture nasal
inferior turbinate (30930), lavage by cannulation (31000), nasal/sinus endoscopy (31296, 31295, 31276, 31256,
31267, 31240), and septoplasty (30520), to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the excision inferior turbinate, fracture nasal inferior turbinate (30930),
lavage by cannulation, nasal/sinus endoscopies, and septoplasty. You say that the services are medically
necessary. The Plan denied your request. The Plan says you must receive your care from a 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
the excision inferior turbinate (30130), fracture nasal inferior turbinate (30930), lavage by cannulation (31000),
nasal/sinus endoscopy (31296, 31295, 31276, 31256, 31267, 31240), and septoplasty (30520), to be provided
by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on June 14, 2019.
You asked the Plan to pay for the x-ray services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not filed timely per Medicare guidelines.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a corrected claim for the x-ray services was not filed until March 31, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the x-ray services provided on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 11,
2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the hospital staff failed to obtain authorization and the doctor should not be penalized. You say the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent nursing facility care provided on February 11, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 (BLS) HCPCS code. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the
appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called.
Medicare requires the reporting of A0428 for services provided under these circumstances. 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 the ambulance services provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing represented by code G0483 provided on
February 1, 2021.
You asked the Plan to pay for code G0483. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says the medical records do not support the billing of code
G0483.
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 G0483 is Drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain
evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we
decided that Medicare rules for coverage of code G0483 have not been met. Therefore, we decided that the
Plan does not have to pay for the drug testing represented by code G0483 provided on February 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinical crown lengthening (D4249) and removable prosthodontic procedure (D5899) provided on March 30, 2021.
You asked the Plan to pay for the clinical crown lengthening and removable prosthodontic procedure. You say that the crown lengthening was part of the process so you could receive a root canal. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to the services being rendered to verify benefits and provider eligibility.
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 (D4249) and removable prosthodontic procedure (D5899) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (99203), to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that the service is medically necessary, and you have seen this provider before. The Plan denied your request. The Plan says you do not have an emergent or urgent medical condition or need specialized service(s) that are not available in the network. There are in network provider(s) within a reasonable distance from your location that can provide this service or item.
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 the office visit (99203), to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 8, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 8, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the drug testing (80307) rendered by the out-of-network (OON) provider on September 23, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99214) and the drug testing (80307) rendered by the out-of-network (OON) provider on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and the unspecified adjunctive procedure, by report (D9999) received August 5, 2020 from the Medicare opt-out provider.

You asked the Plan to pay for the dental services. You say that the Plan should cover these services. The Plan denied your request. The Plan says the provider in this case was opted out of Original Medicare on this 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 among those covered under this benefit when they are received from a provider who has opted out of Original Medicare. The Plan has submitted evidence that this provider was opted out of Original Medicare on this date of services. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and the unspecified adjunctive procedure, by report (D9999) received August 5, 2020 from the Medicare opt-out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the enrollee was admitted with acute hypoxic respiratory failure and a history of NASH cirrhosis. The enrollee continues to require acute care services and has oxygen saturations that require high level of oxygen support indicating that she is not clinically stable. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The LTACH services are therefore not reasonable or medically necessary.

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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.

You asked the Plan to pre-approve continued services. You say that the enrollee's depressive disorder significantly impairs his ability for self-care. The Plan denied your request. The Plan says the enrollee has no acute symptoms that require 24-hour inpatient care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

Continued services from July 28, 2021, forward were requested. 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 continued services. Our physician reviewer found that active treatment was not taking place.

The services were not reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records, the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question. The enrollee could be treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions. He was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 5 through February 6, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that there was concern that the enrollee was having a stroke. The Plan denied your request. The Plan says an inpatient stay was not medically necessary.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found at the time of admission, acute stroke had been essentially ruled out and the enrollee was relatively stable. Based on the above presentation, this enrollee appeared to be expected to require hospital care that would not likely cross two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 5 through February 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on August 18, 2020.

You asked the Plan to pay for the physical therapy 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the
qualifications of a therapist.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services.
Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on August 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on February 3, 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 a $35 copayment for an in-network specialist visit for Medicare-covered services. 

You have been asked to pay a $35 copayment for the specialist visit provided. 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 office visit (99214) provided on February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services 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. 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. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99214) provided May 19, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you want a refund because you feel that you were misdiagnosed with having shingles and you do not have shingles. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $65 copayment for each urgent care visit.
You have been asked to pay $65 copayment for the office visit. The office visit falls within the Urgently needed 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 the outpatient office visit (99214) provided May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an orthosis (L0457) provided to the enrollee on March 17, 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 there is evidence of misrepresented services.

The Plan must follow Medicare rules. Medicare rules say that DME supplies must be provided with a proof of delivery. 

The required documentation pertaining to the proof of delivery of these supplies was not provided. 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 an orthosis (L0457) provided to the enrollee on March 17, 2021.