Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME provided on April 7, 2020.
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says non-emergent, non-urgent
services with out-of-network providers require 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 did not pre-approve the
DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the
Plan does not have to pay for the DME provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services (81225, 81230, 81231, 81232, 81240, 81241, 81283, 81291, 81328, 81335, 81350, 81408) provided on June 3, 2020.
You asked the Plan to pay for genetic testing services. You say that these tests were medically necessary. The Plan denied your request. The Plan says these tests were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one HCPCS codes must be submitted for the panel.
We looked at the file and Medicare rules. The record shows that these tests were performed in parallel and should be reported with a single HCPCS code. Based on this information, we decided that Medicare rules for coverage of genetic testing services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing services (81225, 81230, 81231, 81232, 81240, 81241, 81283, 81291, 81328, 81335, 81350, 81408) provided on June 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 9, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says with
limited exceptions, the enrollee must use network providers to get medical care and services. The only
exceptions are emergencies, urgently needed services when the Plan's network is not available, out-of-area
dialysis services, and cases in which the Plan authorizes use of
out-of-network providers.
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
physician's services. 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 physician's services provided on September 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe breast ultrasound provided on July 9, 2020.You asked the Plan to waive the copay forthe ultrasound. You say that the mammograms are notconclusive, so an ultrasound is required, making it preventative.The Plan denied your request. The Plan says the claim processed 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 $275 copay for each Medicare-covered diagnostic radiology test. You have been asked to pay $178.60 for the ultrasound. Because the amount is lessthan the $275 copay, you were charged the lesser amount. Theultrasound falls within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copay forthe breast ultrasound provided on July 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you need more intensive therapy.The Plan denied your request. The Plan says you do not need nor would fully benefit from the intensity of services of an IRF.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and acute on chronic congestive heart failure. Medical conditionsare stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.There is not a reasonable expectation that this patient 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services from January 12,
2021 forward.
You asked the Plan to pre-approve additional inpatient psychiatric hospital services. You say that the enrollee
needs additional inpatient psychiatric services. The Plan denied your request. The Plan says the enrollee can be
treated in a lower level of care such as Outpatient Treatment.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 additional inpatient psychiatric hospital
services. Our reviewer says that the service is not medically necessary. Our physician reviewer found it did not
appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care
rather than a lower level of care beyond the dates in question as the enrollee did not have dangerousness to self
or others but was compliant with treatment. The health plan's denial of continued inpatient psychiatric services
is appropriate. It did not appear that active treatment was taking place beyond the date in question. It did not
appear that the services were reasonably expected to improve the patient's condition or for the purpose of
diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire
chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon
review the records provided for the admission of this patient does not meet the criteria for continued acute
inpatient mental health treatment for the dates in question of January 12, 2021 forward as this patient was not
shown to be a danger to self or others. The enrollee was not showing any auditory or visual hallucinations and
was cooperative/compliant with treatment while not showing any threats the safety as this patient awaited
placement.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional inpatient psychiatric hospital services have not been met. Therefore,
we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services from January 12,
2021 forward.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe new patient office or other outpatient visit (99204) provided on April 24, 2020.You asked the Plan to pay forthe new patient office or other outpatient visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says that the provider is excluded or debarred from participation in State and Federal health care programs.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the new patient office or other outpatient visit have been met. Specifically, the Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. We performed a search of the List of Excluded Individuals/Entities from the Office of Inspector General and did not find that you were on this list. Without documentation showing that you are excluded from received Medicare reimbursement, the denial cannot be substantiated, and we must find in your favor.Therefore, we decided that the Plan has to pay forthe new patient office or other outpatient visit (99204) provided on April 24, 2020.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 toopen the case again, we will send you a letter
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe urinalysis, manual test (81002), the established patient office or other outpatient visit (99214, 99215) and the established patient periodic preventive medicine examination (99397) provided on April 21, 2020, to May 1, 2020.You asked the Plan to pay forthe urinalysis, manual test, the established patient office or other outpatient visit, and the established patient periodic preventive medicine examination. You say that you would like these claims reprocessed and approved for payment.The Plan denied your request. The Plan says that you are excluded or debarred from participation in State and Federal healthcare programs.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the urinalysis, manual test, the established patient office or other outpatient visit, and the established patient periodic preventive medicine examination have been met. Specifically, the Plan did not provide documentation to show that you are excluded from receiving Medicare reimbursement. We performed a search of the List of Excluded Individuals/Entities from the Office of Inspector General and did not findthat you were on this list. Without documentation showing that you are excluded from received Medicare reimbursement, the denial cannot be substantiated, and we must find in your favor.Therefore, we decided that the Plan has to pay forthe urinalysis, manual test (81002), the established patient office or other outpatient visit (99214, 99215) and the established patient periodic preventive medicine examination (99397) provided on April 21, 2020, to May 1, 2020.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on September 21, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for NovaFix, per square centimeter provided on March 11, 2020.
You asked the Plan to pay for NovaFix. You say that the Plan should pay this claim. The Plan denied your
request. The Plan says the documentation submitted did not include documentation NovaFix, per square
centimeter was applied.
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 Q4208 is NovaFix, per square centimeter.
We find that CPT code Q4208 is not supported in the medical record. Specifically, there is no mention of
NovaFix in the medical notes. Based on this information, we decided that Medicare rules for coverage of
NovaFix have not been met. Therefore, we decided that the Plan does not have to pay for NovaFix, per square
centimeter provided on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for MRI, abdomen; without contrast material(s), followed by
with contrast material(s) and further sequences (CPT Code 74183).
You asked the Plan to pay for the MRI. You say that the MRI is needed in order to have the procedure. The
Plan denied your request. The Plan says multiple attempts were made to obtain records from the provider. The
Plan states that a call placed to the provider's office found that you only had one visit to their office as a new
patient. The Plan states the provider's office was not aware of what the cardiac procedure is that is scheduled
for Monday.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. There
were no medical records provided to verify why this request is needed and to verify what procedure you are
having. Therefore, we decided that the Plan does not have to pay for MRI, abdomen; without contrast
material(s), followed by with contrast material(s) and further sequences (CPT Code 74183).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveosteogenesisstimulator, electrical, non-invasive, spinal applications (CPT Code E0748).You asked the Plan to pre-approvethe DME. You say that the bone stimulator will help fractured bones heal faster and stronger.The Plan denied your request. The Plan says this is not covered for C-spine fracture without spinal fusion.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Medicare guidance says a spinal electrical osteogenesis bone stimulator is only covered if you have a special spinal surgery called spinal fusion.Therefore, we decided that the Plan does not have to pre-approveosteogenesis stimulator, electrical, non-invasive, spinal applications (CPT Code E0748).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 23, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior
authorization was not obtained under the Plan benefits.
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
physician's services. 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 physician's services provided on August 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe rental of a portable oxygen concentrator from an out-of-network provider.You asked the Plan to pre-approvethe DME. You say that you want to be able to use a credit that was given to you at another DME location.The Plan denied your request. The Plan says this provider is out-of-network and the services are not urgent or emergent.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-approvethe rental of a portable oxygen concentrator from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatmentwith an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have notbeen met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 medicallyreasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness after a recent COVID 19 infection. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not requiretreatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 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-approveacute IRF admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea high frequency chest wall oscillation device.You asked the Plan to providea high frequency chest wall oscillation device. You say that the enrollee needs a high frequency chest wall oscillation device.The Plan denied your request. The Plan says criteria is not met for a high frequency chest wall oscillation device.The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.The record does not show that you havecystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that you do not have a medical condition for which a high frequency chestwall oscillation device can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to providea high frequency chest wall oscillation device.