Persius/hicric huggingface dataset:
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 SNF admission. You say that the enrollee requires SNF care. The Plan 
denied your request. The Plan says the enrollee has clinically improved and daily skilled services are not 
required. 
 
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 SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the beneficiary is an 84-year-old 
male who was admitted to the acute inpatient setting on 7/29/2020 for the treatment of severe sepsis due to UTI 
with AKI and E coli bacteremia. Issue in appeal is whether or not the enrollee meets the Medicare criteria for 
SNF admission. From a nursing perspective, the beneficiary received oral medications. The beneficiary had 
stable vital signs. He was alert with confusion. He was treated for a UTI. Regarding rehabilitation services, the 
beneficiary received PT and OT in the acute hospital. The beneficiary was at a supervision to contact guard 
assist level with functional mobility including gait to 320 feet with a rolling walker. The beneficiary required 
varying assist with ADLs. 
 
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; 
however, skilled therapy is not required on a daily basis. 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 SNF 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on December 19, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says 
that the member's primary care physician did not refer these services. 
 
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 lab services provided on December 19, 2019 by an 
out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 4, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
there is no authorization for the services 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 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 a domiciliary, rest home visit provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on January 16, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 
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 laboratory services provided on January 16, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for after hour medical services (99053) provided on February 1, 
2020. 
 
You asked the Plan to pay for the medical services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says payment for this service is always bundled into 
another service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 
AM at 24-hour facility, in addition to basic service. 
 
We find that CPT code 99053 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code 99053 has a status indicator of B. This means that the payment for CPT code 99053 is always bundled 
into the payment for another service. Based on this information, we decided that Medicare rules for coverage of 
the medical services have not been met. Therefore, we decided that the Plan does not have to pay for after hour 
medical services (99053) provided on February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on December 19, 2019 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 lab work provided on December 19, 2019 by an 
out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on March 12, 2020.
You asked the Plan to waive the copayment for an emergency room visit. You say that you had to go back
because they inserted your catheter wrong the first time. The Plan denied your request. The Plan says the
correct copayment has been applied.
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 emergency care.
You have been asked to pay a $90 copayment for an emergency room visit. Since emergency room services
were provided, the correct copayment has been applied. An emergency room visit falls within the emergency
care 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 an emergency room visit
provided by a participating provider on March 12, 2020.
We note your complaint about having to go back to the ER because of your first visit. Your complaint is a
grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types
of complaints.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on August 14, 2019 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that 
the member's primary care physician did not refer these services. 
 
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 member's primary care 
physician did not request these services. 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 lab work provided on August 14, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 26, 2020. You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not authorized. The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the services provided on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora duplex scan provided on February 5, 2020 by an out of network (OON) provider.You asked the Plan to pay fora duplex scan. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The plan says that the member's primary care physician did not refer these services.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 duplex scan provided on February 5, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member just moved. You say that the member did not have time to get a local plan prior to being seen. The Plan denied your request. The Plan says prior authorization was not obtained for these services.
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 an office visit provided on November 4, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from 
September 6, 2019 to October 31, 2019. 
 
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 an invalid or missing FIPS code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the denied codes are not supported in the medical record. Specifically, the corrected claim that 
was submitted does not have the appropriate home health data (FIPS Value Amount). 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 home health services provided to the enrollee from September 6, 
2019 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
November 5, 2019.
You asked the Plan to pay for physician services provided to the enrollee. You say that this claim should be
paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of
network care.
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 has network providers available
who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 out of network physician services provided to the enrollee on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (CPT 87633) provided on April 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that LCA A57579 provides a list of non-covered CPT codes. We looked at the file and Medicare rules. Per A57579, CPT code 87633 is a non-covered code. 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 lab services (CPT 87633) provided on April 3, 2020.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the lumbar puncture billed with code 62272 provided on December 23, 
2019 by an anesthesia provider prior to an endovascular aortic repair. 
 
You asked the Plan to pay for the lumbar puncture. You say that this should be paid as a distinct service. The 
Plan denied your request. The Plan says that this cannot be separately paid when anesthesia is provided. Other 
anesthesia is included in the anesthesia service and is not separately reportable. The NCCI Manual says that if a 
physician performing a spinal puncture for intrathecal injection administers an anxiolytic agent, the vascular 
access and any appropriate monitoring is considered part of the spinal puncture procedure and is not separately 
reportable. 
 
Please note, we reviewed the cited section from the NCCI Manual and we find that it does not apply to 
therapeutic spinal drains where no anesthetic is injected. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Certain procedures are considered bundled into 
other reported services if they are integral to the other reported service. In this case, the CPT Code Manual 
definition of code 62272 is Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or 
catheter).  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the lumbar puncture. Our reviewer says that 
this service is not considered integral to anesthesia for this procedure and is not bundled with the anesthesia 
code. Our physician reviewer found this 71-year-old man had a pseudo-aneurysm of the aorta and underwent 
an endovascular repair. A spinal drain was placed prior to the procedure to protect spinal cord perfusion. The 
patient received general anesthesia for the procedure. This is a separate procedure and is not an anesthetic. It is 
done to reduce the risk of spinal cord injury from the procedure. This procedure was medically necessary and is 
billed separately.  
 
 
 
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 lumbar puncture have been met. Therefore, we decided that the Plan has to 
pay for the lumbar puncture billed with code 62272 provided on December 23, 2019 by an anesthesia provider 
prior to an endovascular aortic repair.  
 
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 for ambulance care provided December 27, 2018. 
 
You asked the Plan to pay for the ambulance care. You say that the claim should be paid. The Plan denied your 
request. The Plan says since this ambulance did not provide transport, the service is not eligible for Medicare 
payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 27, 2018. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance care provided December 27, 2018.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for paramedic intercept services provided to the enrollee on 
August 3, 2019. 
 
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 this is an invalid procedure code for this service. 
 
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 in a rural area.  
 
The paramedic intercept services at issue in this appeal were not furnished in a rural area. Therefore, we 
decided that the Plan does not have to pay for paramedic intercept services provided to the enrollee on August 
3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CT scan provided on August 16, 2019.You asked the Plan to pay forthe CT scan. You say that the enrollee was not on hospice at the time of service.The Plan denied your request. The Plan says Original Medicare is responsible for payment.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 August 16, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe CT scan provided on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (99213) provided on February 4, 2020. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says this service is included in another service provided at 
the same time by the same provider. 
 
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 99213 is office or other outpatient visit for the evaluation 
and management of an established patient, which requires at least 2 of these 3 key components: An expanded 
problem focused history; An expanded problem focused examination; Medical decision making of low 
complexity. Counseling and coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are 
spent face-to-face with the patient and/or family.  
 
We find that CPT code 99213 is not supported in the record. Specifically, the record indicates that another 
evaluation and management code has been paid to this provider, for this member on the same date of service.  
 
If more than one evaluation and management service is provided on the same day to the same member by the 
same physician or more than one physician in the same specialty in the same group, only one evaluation and 
management service may be reported unless the evaluation and management services are for unrelated 
problems. Based on this information, we decided that Medicare rules for coverage of the office visit have not 
been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213) provided on 
February 4, 2020.