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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 14, 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on January 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Power Bed Lift Chair purchased on February 29,
2020 from a non-Medicare provider.
You asked the Plan to pay for the DME. You say that you are requesting reimbursement of services rendered.
The Plan denied your request. The Plan says they did not receive a prior authorization for DME that cost over
$1000 and the provider is not Medicare certified.
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 plan did not received a prior authorization for the DME that costs over $1000. Furthermore, the provider
does not participate in the Medicare program. The rules say that to receive payment for covered Medicare items
or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an
unassigned claim), a provider or supplier must be enrolled in the Medicare program. Therefore, we decided that
the Plan does not have to pay for a Power Bed Lift Chair purchased on February 29, 2020 from a non-
Medicare provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an electrocardiogram (93005) and a
cystourethroscopy (52332) provided from December 3, 2019 to December 11, 2019.
You asked the Plan to waive the copayment for an electrocardiogram and a cystourethroscopy. You say that
this should be paid. The Plan denied your request. The Plan says these services 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 $90
copayment for diagnostic tests and a $290 copayment for surgical services provided in an outpatient hospital
setting..
You have been asked to pay $53.21 for an electrocardiogram because the allowed amount is less than your
listed copayment, and $290 a cystourethroscopy, which is an outpatient surgical 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 electrocardiogram (93005) and a cystourethroscopy (52332)
provided from December 3, 2019 to December 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora PET-CT scan provided on December 27, 2019 by an out of network (OON) provider.You asked the Plan to pay fora PET-CT scan. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services could have been provided in-network.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 has network providers available who can provide 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 fora PET-CT scan provided on December 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tracheotomy tube change (31502) provided on February 6, 2020.You asked the Plan to pay for the tracheotomy tube change. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says procedure code 31502, tracheotomy tube change prior to establishment of fistula tract, is a code that should never be performed in Place of Service 11.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 31502 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 31502 has a non-facility indicator of NA. This means that this service is rarely or never performed in a non-facility setting. CPT code 31502 has been billed with a non-facility place of service code. Based on this information, we decided that Medicare rules for coverage of the tracheotomy tube change have not been met.Therefore, we decided that the Plan does not have to pay fora tracheotomy tube change (31502) provided on February 6, 2020.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission 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 medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you required moderate assistance with upper body dressing. You required moderate independent with a rolling walker for gait. You required moderate/maximum assistance with transfers. You were dependent for bed mobility. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however, your functional level does not indicate that this therapy must be in an IRF with an intensive level program.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0481 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0481 is definitive drug testing, 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, there is no documentation of testing of 8-14 drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided January 4, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that you thought the man who came and provided first aid was a part of the crew that was taking you to the hospital and you should not have to pay for this. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that there is no contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided January 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic footwear (L3230) provided on January 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON orthopedic footwear. You say that you believe you met requirements for these items. The Plan denied your request. The Plan says these items 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 has network providers available who can provide 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 orthopedic footwear (L3230) provided on January 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival flap procedure (D4241) and bone replacement graft (D4263) provided on January 9, 2020.
You asked the Plan to pay for the gingival flap procedure and bone replacement graft. You say that it was in the enrollee's best interest to save this tooth. You also say that a clinical decision was made to further explore the lesion. The Plan denied your request. The Plan says these services are not covered benefits under the enrollee's dental plan.
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 gingival flap procedure (D4241) and bone replacement graft (D4263) provided on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transport taxi (A0100) provided on January 8, 2020 to January 23, 2020 by an out of network (OON) provider.You asked the Plan to pay for the non-emergency transport taxi. You say that there are no physical therapists in your area and you do not have transportation and used Uber and Lyft to get there The Plan denied your request. The Plan says you must receive your services from a network provider. The providers are not in-network transportation providers and are not certified with Medicare.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 and is not certified with Medicare. The Plan has network providers available who can provide 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 non-emergency transport taxi (A0100) provided on January 8, 2020 to January 23, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 14, 2019 through March 20, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of admission the provider felt the patient would require medically necessary hospital care that was expected to span two (2) or more 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from March 14, 2019 through March 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the inpatient SNF care. You say that you believe that this level of care is necessary. The Plan denied your request. The Plan says less than daily skilled services would meet this enrollee's needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 inpatient SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 65 year old female with rib pain after a fall, CKD with hyperkalemia, hypertension, urinary retention with urostomy, breast cancer. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. She was treated for pain with effect. She had routine urostomy care. Regarding rehabilitation services, there are no daily skilled services noted or required. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. This beneficiary 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 inpatient SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (LT, RT) L1812 and knee control full kneecap (LT, RT) L2795 provided April 8, 2019.You asked the Plan to pay forthe orthoses. You say that you ware appealing with the attached medical records, deliver confirmation (PPA) and documentation showing what device was delivered. Please reprocess the claim correctly.The Plan denied your request. The Plan says the documentation received does not support the coding (L1812, L1812, L2795, L2795). There was no  coding on the patient product agreement or the prescription to support what was provided to the enrollee.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (LT, RT) L1812 and knee control full kneecap (LT, RT) L2795 provided April 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 9, 2019.
You asked the Plan to pay for drug test. You say that you are appealing with the lab order and records to support payment. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
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 documentation submitted shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on April 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foroxygen concentrator (E1390)provided on September 14, 2019.You asked the Plan to waive the coinsurance forthe DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). When you receive durable medical equipment and related supplied you are responsible for a 20% coinsurance for Medicare-covered benefits. On September 14, 2019 claim for your rental of oxygen concentrator was billed which applied a 20% coinsurance. The allowed amount for this service is $81.01, $81.01 X 20% = $16.20. Therefore, you would have been assessed a $16.20 cost share which you were and the cost share was correctly applied per your benefits and is your responsibility. 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 coinsurance foroxygen concentrator (E1390) provided on September 14, 2019.
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 you want to start rehab as soon as possible. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital with abdominal pain, shortness of breath, and vomiting. The physical therapy note on June 12, 2020 states that you are able to complete transfers from sitting to standing and can walk 10 feet. The note on June 14, 2020 states you are medically stable and awaiting placement. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program 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 pay for the Hepatitis A vaccine (90632) provided on March 6, 2020.
You asked the Plan to pay for the Hepatitis A vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the vaccine received is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A vaccine. Therefore, we decided that the Plan does not have to pay for the Hepatitis A vaccine (90632) provided on March 6, 2020.
Benefits for the Hepatitis A vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights