Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided August 15, 2019.
You asked the Plan to pay for the orthoses. You say that please review the records and reverse the decision to deny. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no 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 non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthosis (L1851) and suspension sleeve (L2397) provided August 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs LTACH care. The Plan denied your request. The Plan says an LTACH cannot provide any service that cannot be provided in the current facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient is currently undergoing treatment at an ACH for a sternal wound infection following coronary bypass surgery late last year. The enrollee has undergone surgical debridement. He continues to receive wound care and antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 22, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is Drug test(s), definitive, utilizing (1) drug
identification methods able to identify individual drugs and distinguish between structural isomers (but not
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type,
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g.,
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drugspecific
calibration and matrix-matched quality control material (e.g., to control for instrument variations and
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or
more drug class(es), including metabolite(s) if performed.
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requsition or medical records signed by the ordering
physician stating exactly what tests were to be performed. Also, the submitted order indicates that only 11 drug
classes were ordered. Based on this information, we decided that Medicare rules for coverage of the drug
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded
G0483 provided on July 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood pressure monitor or blood pressure monitoring
provided on August 27, 2019.
You asked the Plan to pay for a blood pressure monitor or blood pressure monitoring during an ambulance
transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says ambulatory
blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24
hours.
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 A4670 is automatic bp monitor, dial.
We find that CPT code A4670 is not supported in the medical record. Specifically, the enrollee did not receive
a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately
payable. Based on this information, we decided that Medicare rules for coverage of blood pressure monitoring
during an ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for
a blood pressure monitor or blood pressure monitoring provided on August 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on August 14, 2019.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the copayment is excessive for the colonoscopy. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $300 copayment for each Medicare-covered ambulatory surgical center visits. You have been asked to pay a $300 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the diagnostic colonoscopy provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on May 17, 2019.
You asked the Plan to pay for the genetic testing. You say that the referring physician sent a specimen to your laboratory and these services are an extension of the initial office visit. The Plan denied your request. The Plan says that non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case and the referring provider are not network providers 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 the genetic testing provided on May 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ratchet-style positional upper extremity prostheses for enrollee.You asked the Plan to pre-approve the requested prostheses. The Plan denied your request. The Plan says the records do not show why a single-grip prosthesis will not meet the enrollee's needs.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 requested prostheses. Our physician reviewer found that the enrollee lost her fingers 2-5. Her thumb was spared, and she is left including only the carpal structures of the hand. She has worked with massage therapy and now has soft tissue healing, and range of motion at the wrist that is within functional limits. There is no indication that a standard single-grip prosthesis could not safely and adequately address needs. The requested item is a convenience item and is deemed 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 the requested prostheses have not been met. Therefore, we decided that the Plan does not have to pre-approve ratchet-style positional upper extremity prostheses for enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee from January 15, 2020 to discharge.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our physician reviewer found based upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 15, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee from January 15, 2020 to discharge.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and application of fluoride (D1206) provided on January 9, 2019.
You asked the Plan to pay for the dental services. You say that you have been going to this office for 5 years. You say that you asked the provider's office if your insurance was accepted. You say that you were advised that it was. You also say that had you been advised your insurance was not accepted you would have not had the services. The Plan denied your request. The Plan says dental services received out of network are not covered.
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 and the services are listed as covered, they are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120), bitewing x-rays (D0274), prophylaxis (D1110), and application of fluoride (D1206) provided on January 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 12, 2019.You asked the Plan to waive the copayment for laboratory services. You say that these services were a result of a previous procedure. You say that you do not want to pay the bill.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 $20 for Medicare-covered laboratory tests. You have been asked to pay $12.49, which is less than the standard $20 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 laboratory services provided on September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric/detox care provided from August 24, 2019 to August 30, 2019.
You asked the Plan to pay for the inpatient psychiatric/detox care. You say that the patient has Medicare as the primary insurance and has the Plan as the secondary insurance and that is why a prior authorization was not obtained. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. The Plan also says that inpatient mental health care requires 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 contract with the Plan also says that inpatient mental health care requires prior authorization. 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 inpatient psychiatric/detox care provided from August 24, 2019 to August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulative treatments (98941) provided on June 27, 2019 to July 1, 2019 by the out of network provider.
You asked the Plan to pay for chiropractic manipulative treatments. You say that you are appealing the claim payment denial for services rendered to the member on dates of service June 27, 2019 through July 1, 2019. Although authorization was not obtained, services rendered were medically necessary due to the nature of the patient's condition. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The referring provider listed is also a non-participating provider. The plan did not authorize any services for the facility or physician who are non-participating providers. The services were not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the 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 chiropractic manipulative treatments (98941) provided on June 27, 2019 to July 1, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided from May 24, 2019 to August 12, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of
Delivery did not include details to corroborate the Delivery Ticket.
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.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have
a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose
monitor, test strips, lancets, control solution, and lancet device provided from May
24, 2019 to August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for gait trainer, pediatric size, upright support, includes all accessories and components (CPT Code E8001) provided to the enrollee on August 28, 2019.
You asked the Plan to pay for the gait trainer. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
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 gait trainer have not been met. This is not a benefit of Medicare and is not covered by Medicare in any payment system. Therefore, we decided that the Plan does not have to pay for gait trainer, pediatric size, upright support, includes all accessories and components (CPT Code E8001) provided to the enrollee on August 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions (D7410) for teeth # 7, and 8, and the incision and drainage of an abscess (D7510) provided on April 16, 2019.You asked the Plan to pay for the extractions for teeth # 7 and 8, and the incision and drainage of an abscess. You say that you have a $1,000 limit for dental services. You also say that the services you received should be covered.The Plan denied your request. The Plan says the frequency limit of 2 extractions per year has been exceeded. The Plan also says that the incision and drainage of an abscess is not a covered service.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 and extractions are a covered service, the frequency limit has been exceeded. The Plan paid for the extraction of teeth # 4 and 6. Additionally, the incision and drainage of an abscess is not a covered service.Therefore, we decided that the Plan does not have to pay for the surgical extractions (D7410) for teeth # 7, and 8, and the incision and drainage of an abscess (D7510) provided on April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 18, 2018 by out of network provider.You asked the Plan to pay for office visit. You say that you are appealing.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 prior 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 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 forthe medical services provided on October 18, 2018 by out of network provider.