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

We decided that the Plan does not have to pay for the domiciliary, rest home visit (99336) provided on December 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary, rest home visit. You say that attached is the medical record which will show medical necessity for these claims. Please review the requested medical records for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary, rest home visit (99336) provided on December 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673 X2) and pneumatic compression device (CPT Code E0675) provided to the enrollee on January 27, 2021.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the pneumatic compression device and/ or supplies is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with
venous stasis ulcers. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Records show that the DME was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance (CPT code E0673 X2) and pneumatic compression device (CPT Code E0675) provided to the enrollee on January 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transportation service
provided on October 21, 2020.

You asked the Plan to waive the copayment for an ambulance transportation service. You say that you disagree
with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $225
copayment for each one-way ambulance transport received out-of-network.

You have been asked to pay a $225 copayment for an ambulance transportation service. The EOC is clear that
$225 is the required copayment for this service. 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 an
emergency ambulance transportation service (A0427) provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on October 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal autograft services provided during a covered spinal surgery on December 10, 2020, billed with code 20936.
You asked the Plan to pay for the autograft services. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says payment has been approved for this surgery; however, payment cannot be made for code 20936.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
CPT code 20936 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this code is always bundled into other services provided. Therefore, we decided that the Plan does not have to pay for the spinal autograft services provided during a covered spinal surgery on December 10, 2020, billed with code 20936.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging of the spinal canal (72148) provided on December 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the magnetic resonance imaging. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or 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 the magnetic resonance imaging of the spinal canal (72148) provided on December 31, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on November 16, 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 are not covered when performed by a chiropractor.
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. The file shows that the provider billed codes 98943 (extraspinal manipulation), G0283 (electrical stimulation), and 97012 (mechanical traction therapy). Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on November 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 8, 2020 by a non-participating provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 8, 2020 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 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 services provided by an out-of-network provider on February
9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 16, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was not obtained in the laboratory setting. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional physical therapy visits and 1 additional occupational therapy visits.
You asked the Plan to pre-approve 6 additional physical therapy (PT) visits and 1 additional occupational therapy (OT) visits. You say that the enrollee needs additional therapy. The Plan denied your request. The Plan says the enrollee should have had any training or education needed by the OT and PT services already had.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 6 additional physical therapy (PT) visits and 1 additional occupational therapy (OT) visits. Our reviewer says that the therapy services are not medically necessary. Our physician reviewer found in this case, the documentation doesn't support that the member requires additional skilled rehab services to provide treatment that is medically necessary. The member does not require skilled rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not 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 6 additional physical therapy (PT) visits and 1 additional occupational therapy (OT) visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional physical therapy visits and 1 additional occupational therapy visits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual urinalysis, urine bacteria culture, and evaluation
of antimicrobial drug provided on July 29, 2020.
You asked the Plan to pay for the manual urinalysis, urine bacteria culture, and evaluation of antimicrobial
drug. You say that the enrollee's hospice coverage terminated on July 23, 2020. The Plan denied your request.
The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or
unrelated to the enrollee's terminal condition.
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. The enrollee ended Medicare Hospice benefits on July 23, 2020. 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 manual urinalysis, urine bacteria culture, and evaluation of antimicrobial drug provided on July 29, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychotherapy visit provided on December 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that this service was provided with no adequate timeframe to obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 psychotherapy visit provided on December 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation.

You asked the Plan to pre-approve lumbar facet joint radiofrequency ablation. You say that the requested service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for lumbar facet joint radiofrequency ablation have not been met.

The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation services are subject to the criteria listed 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 lumbar facet joint radiofrequency ablation. Our reviewer says that the requested service does not meet the relevant coverage criteria. Our physician reviewer found the LCD requires 2 sets of diagnostic MBBs, both of which produce greater than 80% pain relief. Only one set has been done. Therefore, at this time, the requested services are not medically reasonable and 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 lumbar facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar facet joint radiofrequency ablation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (CPT code
22513), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee's pain is increasingly getting worse.
The Plan denied your request. The Plan says the request is not medically necessary because the enrollee's
symptoms are chronic and there is no recent imaging to confirm a fracture was sustained within the last twelve
(12) weeks as required by Medicare rules.
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 surgery have not been met. Review of the records do not show
the enrollee has a recent fracture in their back. Therefore, we decided that the Plan does not have to preapprove
percutaneous vertebral augmentation (CPT code 22513), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy provided by a chiropractor on February 22, 2021.
You asked the Plan to pay for infrared therapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is non-covered for the treatment of the enrollee's condition.
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 infrared therapy provided by a chiropractor on February 22, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided by an out-of-network provider on November 3, 2020.
You asked the Plan to pay for the psychotherapy. You say that the service was provided with no adequate time to obtain authorization. You say that the records reflect the medical necessity of the service and the claim should be processed for payment. The Plan denied your request. The Plan says authorization for out of network services was not 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 psychotherapy provided by an out-of-network provider on November 3, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve the CT scan. You say that the clinical documentation provided supports the need for the requested CT scan. The Plan denied your request. The Plan says that the records show the same test or one like it is on file for the enrollee and is still in effect. The Plan says that the records do not show the results of this study, of if there are plans for the study. The Plan says that the approved study may show the enrollee's doctor what they needed to see in order to treat the condition. The Plan says that further imaging cannot be approved without knowing the outcome of the prior approved study.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee has a history of hepatocellular carcinoma with previous metastases in 2010. Our physician reviewer found that there is now a concern that the enrollee has a recurrence. He is currently undergoing treatment and needs monitoring with imaging to determine response. 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on January 23, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the service was 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 laboratory work provided on January 23, 2021 by an out of network (OON) provider.