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

We decided that the Plan does not have to pay for the anesthesia services coded 00731 provided on August 24, 2018.
You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says this claim was a duplicate of a previous submitted claim.
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 00731 is Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified. We find that CPT code 00731 is not supported in the medical record. Specifically, these services were provided while the enrollee was inpatient. These anesthesia services were a duplicate to a previous submitted claim. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00731 provided on August 24, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from August 25, 2019 through August 26, 2019. You asked the Plan to waive the copayment for the observation stay. You say that you were in the critical decision unit not under observation. You say that you should not owe the copayment. The Plan denied your request. The Plan says the copayment applied 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 $225 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room or outpatient surgery services. You have been asked to pay a $225 copayment for the observation stay. The observation stay falls within the "Outpatient Hospital Services" benefit category. The records show that you were admitted to observation. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the observation stay provided from August 25, 2019 through August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by an out of network provider. You asked the Plan to pay for the nursing facility visit. You say that the services rendered were medically necessary. The Plan denied your request. The Plan says these services were non-emergent and rendered 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 did not pre-approve the item/service at issue. We foundno 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 medical services provided on July 1, 2019 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99222, 99232, and 99238) provided from August 25,2018 to September 1, 2018.You asked the Plan to pay forhospital care. You say that this claim was filed timely.The Plan denied your request. The Plan says this claim was not filled with correct member information until more than a year after the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for hospital care was not filed until September 27, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forhospital care (99222, 99232, and 99238) provided from August 25, 2018 to September 1, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device with sleeves (E0652 and E0667) to be provided by an out of network provider.
You asked the Plan to pre-approve a pneumatic compression device with sleeves. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says there are in-network options available to receive a segmented pneumatic compression device and sleeves, such as Vasocare.
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 pre-approved care. Medicare rules also say a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E06551 device is required.
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. Furthermore, in order to be covered for a pneumatic compression device described by code E0652, medical records must demonstrate a four-week trial of conservative therapy showing failed response to treatment with an E0650 or E0651 device. The file does not show this. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device with sleeves (E0652 and E0667) to be provided by an out of network provider.
Please note, the Plan states that they will approve a pneumatic compression device with sleeves (E0652 and E0667) with an in-network provider, such as Vasocare.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 6, 2019 by the out of network
provider.
You asked the Plan to pay for an office visit. You say that you were told that you did not need prior
authorization every time you saw the patient. The Plan denied your request. The Plan says no prior
authorization was 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 May 6, 2019 by the out of
network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venous device blood draw provided on
August 22, 2019.
You asked the Plan to waive the copayment for the venous device blood draw. You say that you were
previously only charged a $40 copayment for the same service. You say that you don't understand the
discrepancy in charges. The Plan denied your request. The Plan says the copayment applied 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 $250
copayment for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory
surgical center.
You have been asked to pay $103.44, which is less than the standard $250 copayment for the venous device
blood draw. The venous device blood draw falls within the "Outpatient Surgery and Other Medical Services
Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The venous
device blood draw is considered a 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
the venous device blood draw provided on August 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system for the power wheelchair.You asked the Plan to pre-approvethe expandable control system. The Plandenied your request. The Plan says the enrollee's upper limb strength and function is adequate for the enrollee to control the approved options using their own switches.The Plan follows Medicare rules. Medicare rules say that wheelchair options are only covered under certain medical indications. 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 expandable control system. Our physician reviewer found that the documentation does not reveal that the enrolleerequires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportionalinput device such as sip and puff, or the need to control 3 or more power seating actuators through the drive control. The enrollee'sstrength is sufficient to control the power options with their separate switches already included with the approval of these power options.
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 expandable control system have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable control system for the power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction exam you received on October 7, 2019.
You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Neither Medicare nor your plan covers eye refractions. Therefore, we decided that the Plan does not have to pay for the eye refraction exam you received on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0648) provided to the enrollee on
January 28, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says they were unable to discover any evidence of an established
relationship between the member and the ordering physician. The Plan states there were no claims submitted
for an evaluation and management service. The Plan states the review of claims history for this member, and a
review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service
with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis
(L0648) provided to the enrollee on January 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services rendered to enrollee on July 1, 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 the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of diagnotic services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. The file shows that procedure code 88112 was not billed with the required -26 modifier to allow for separate payment of the PC. 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 cytopathology services rendered to the enrollee on July 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on August 21, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthosis was not met.
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 shoulder-elbow-wrist-hand orthosis (L3960). Our physician reviewer found the enrollee's chief complaint was shoulder pain. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of a credible physical examination of the shoulder.
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 shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on August 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Veltassa for the enrollee.
You asked the Plan to pre-approve Veltassa. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Veltassa for the enrollee.
Benefits for Veltassa may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga.You asked the Plan to pre-approve Farxiga. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules.The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Farxiga.Benefits for Farxigamay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on July 5, 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 codes 36247, 36245, and 36248 are 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 36247 is selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. The definition of code 36245 is selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family. The definition of code 36248 is selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate).
We find that CPT codes 36247, 36245, and 36248 are not supported in the medical record. Specifically, the operative report does not contain documentation of a selective catheter placement into the arterial system to support codes 36247, 36245, and 36248. 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 services rendered on July 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services and psychotherapy provided on September 6, 2019 by out of network provider.You asked the Plan to pay for outpatient hospital services and psychotherapy. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-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 for outpatient hospital services and psychotherapy provided on September 6, 2019 by out of network provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 29, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that it takes a half hour to an hour to set up the Heart Lung Machine and the perfusionist is required to be in the operating room during the length of the procedure. The Plan denied your request. The Plan says the payment for this service is included in the DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, the payment for this service is included in the DRG payment to the facility. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 29, 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 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 supervision with sit to stand and walking 65 feet with a rolling walker. The documentation does not reveal that your medical status required the intensity of an IRF stay with close physician or nursing supervision. While you may benefit and participate in additional therapy of physical therapy and occupational therapy, you do not require this therapy or appear to be able to tolerate therapy on an intensive rehabilitation facility therapy program level 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 office visit rendered to the enrollee on July 23, 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 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 services at issue are an office visit billed with code 99212. Therefore, we decided that the Plan does not have to pay for the office visit rendered to the enrollee on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parenteral nutrition solution (B4185 and B4197) and supply kit (B4224 and B4220) provided on August 17, 2019 through August 23, 2019.
You asked the Plan to pay for the parenteral nutrition solution and supply kit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid order signed by the ordering provider for the billed supply or an itemized shipping/billing invoice to indicate the supplies and proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.