Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the home visits provided on December 2, 2019, December 17, 2019, December 30, 2019. We decided that the Plan does not have to pay for the home visit provided on February 17, 2020.
You asked the Plan to pay for home visits. You say that authorizations should not be needed for telemedicine. The Plan says that this provider is not a network provider with the Plan.
We decided that the Plan has to pay for the home visits provided on December 2, 2019, December 17, 2019 and December 30, 2019.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the 2019 Evidence of Coverage. This means that we cannot confirm that denying based on network status is reasonable or justified by the Plan contract. Therefore, we decided that the Plan has to pay for the home visits provided on December 2, 2019, December 17, 2019, December 30, 2019.
We also decided that the Plan does not have to pay for the home visit provided on February 17, 2020.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided on February 17, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with
suspension sleeve (L1833, L2397) provided to the enrollee.

You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.

The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary
and conducted a face-to-face assessment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the durable medical equipment have not been met. Specifically, medical records do not support a
prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an
appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was
performed. The information submitted does not confirm that Medicare coverage criteria have been met.

Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee
orthosis with suspension sleeve (L1833, L2397) provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on October 5, 2020.
You asked the Plan to pay for the ConfirmMDx 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 payable.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered for males
aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and
are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors, and
We looked at the file and Medicare rules. Review of the file does not support that had a negative prostate
biopsy within 24 months and increasing prostate specific antigen levels. Based on this information, we decided
that Medicare rules for coverage of the ConfirmMDx testing have not been met. Therefore, we decided that the
Plan does not have to pay for the ConfirmMDx testing provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on September 10,
2020, by an OON provider.
You asked the Plan to pay for nursing facility care. You say that the facility failed to verify eligibility and
obtain prior authorization, and you feel the provider should not be held liable. The Plan denied your request.
The Plan says they do not cover out of network care, except in limited circumstances. This care was not urgent
or pre-approved. The provider or the facility are responsible for ensuring that eligibility is verified, and prior
authorization is granted prior to 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the nursing facility care (99309) provided on
September 10, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve paravertebral facet joint injections (right L4-5 and L5-S1 left radiofrequency ablation) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the request exceeds the limitations of coverage.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee previously had two sessions of radiofrequency ablation of the medial branch. The request for repeat procedure exceeds the utilization criteria and therefore, is considered not medically reasonable or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve paravertebral facet joint injections (right L4-5 and L5-S1 left radiofrequency ablation) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (99336) provided by an out of network (OON) provider.

You asked the Plan to pay for the home health services. You say that this was a medically necessary service. The Plan denied your request. The Plan says they only cover out of network services in limited circumstances. The service provided was not urgent or pre-approved.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home health services (99336) provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from
August 29, 2020, to September 3, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that a copayment was
charged for each day in the hospital. The Plan denied your request. The Plan says you have been asked to pay
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 $390
copayment per day, days 1-5 and a $0 copayment per day, days 6-90.
You have been asked to pay a $390 copayment for each day of the inpatient hospital stay. ($390 x 5 days =
$1,950). The inpatient hospital stay falls within the "Inpatient hospital 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 the inpatient hospital stay provided from August 29, 2020, to
September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 20, 2020, by an OON
provider.
You asked the Plan to pay for lab work. You say that you were never told not to go to this provider. The Plan
denied your request. The Plan says 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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab work provided on October 20, 2020, by an
OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 72131 provided on
You asked the Plan to pay for the CT scan. 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 72131 is computed tomography, lumbar spine; without contrast material. We find that CPT code 72131 is not supported in the medical record. Specifically, the documentation submitted did not include documentation that a lumbar spine computed tomography was completed. The documentation shows that a computed tomography of the cervical spine was completed. There is a more appropriate code for the services provided. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan coded 72131 provided on.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on June 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not payable for these services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Lumbar-sacral orthosis (LSO) (L0650) provided on September 9, 2020
You asked the Plan to pay for LSO. You say that the item is medically necessary. The Plan denied your request. The Plan says there is insufficient documentation in this case.
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 pay for LSO. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of an appropriate history and a physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of LSO have not been met. Specifically, there is no documentation indicating the LSO is medically necessary or reasonable for this member. Therefore, we decided that the Plan does not have to pay for Lumbar-sacral orthosis (LSO) (L0650) provided on September 9, 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 the records provided support the need for care in an IRF. You say that the enrollee is motivated to actively participate in progressive therapy program in order to return home. You say that the goal of an IRF stay is to enable the enrollee's safe return to the home or community-based environment upon discharge. You say that the enrollee's treatment goals and achievements during an IRF stay are expected to reflect significant and timely progress toward this end goal. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's needs can safely be met at a less intensive level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure and peripheral vascular disease. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided 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 physician's services provided on October 13, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on October 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 30, 2020.
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 was not reported correctly.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided an out-of-network provider on
November 2, 2020.
You asked the Plan to pay for the nursing facility care. You say that the facility failed to obtain the necessary
authorization. You say that the physician provided medically necessary services and the claim should be
processed for payment. The Plan denied your request. The Plan says authorization for out of network services
was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for nursing facility care provided an out-of-network
provider on November 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0428, A0425, A0999).

You asked the Plan to waive the copayment for the ambulance transportation. You say that this was medically necessary and should be covered at no cost to you. The Plan denied your request. The Plan says ambulance transportation services are subject to a $350 copayment.

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 $350 copayment per trip for ambulance services.

You have been asked to pay a $350 copayment for the ambulance transportation. Ambulance transportation falls within the ambulance services 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 ambulance transportation services (A0428, A0425, A0999).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan.
You asked the Plan to waive the copayment for the CT scan. You say that you cannot afford the copayment. The Plan denied your request. The Plan says you were referred to a non-preferred provider, therefore the correct cost share applied to the claim.
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 outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $250 copayment for the CT scan performed with a non-preferred provider. The CT scan falls 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 the CT scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision exam and eyewear you had on October 5, 2020.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says out-of-network services are not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an in-network provider. We looked at the file and the Plan's rules. The routine vision services were provided by an out-of-network provider. The Plan does not cover out-of-network routine vision care. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for the vision exam and eyewear you had on October 5, 2020.