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

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 11, 2019. 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 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 a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic adjustments provided from November 27, 2019 to December 16, 2019 by an out of network (OON) provider. You asked the Plan to pay for chiropractic adjustments. You say that you truly thought that you had authorization for these dates. The Plan denied your request. The Plan says no prior authorization was obtained. The plan says that there are in-network providers available. 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 adjustments provided from November 27, 2019 to December 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 81162) provided to the enrollee on August 27, 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 the records and results document a Tempus Gene Panel - there is a more appropriate code that represents the services rendered. 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 81162 is "BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements)." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the documentation indicates that Tempus panel testing was planned, ordered and performed. There is no indication that targeted BRCA gene testing was planned, ordered or performed. Therefore, the billing of CPT 81162 is not supported. 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 pay for lab services (CPT 81162) provided to the enrollee on August 27, 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 are currently on dialysis and all of you needs can be managed at this practice. Moving you to a different facility could be detrimental to your health and cause irreparable damage. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for IRF admission.
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 based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. In the absence of medical records, it is hard to determine what the enrollee's needs are. IRF admission is not medically necessary based on his current functional status and inability to weight bear on his lower extremities. 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 medical services provided from March 7, 2019 to September 12, 2019 by an out of network (OON) provider. You asked the Plan to pay for the office visit. You say that you were told by the Plan that these services would be covered. The Plan denied your request. The Plan says there was no preauthorization for this service, no medical emergency and no referral from your primary care physician. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on March 7, 2019 to September 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on October 10, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that the visit should be included in a surgery package and you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $20 copayment for each primary care doctor visit. You had a specialist visit on October 10, 2019. Specialist visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on September 12, 2019. You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says this claim is a duplicate claim of another that's already being considered. The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that are exact duplicates of another claim are to be denied. We looked at the file and Medicare rules. This claim is a duplicate of another claim submitted to the Plan. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on September 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatments provided on December 17, 2019 and December 18, 2019. You asked the Plan to waive the copayment for radiation treatments. You say that the cost is a lot. You say that you want help with the copayment. The Plan denied your request. The Plan says the copayments 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 $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service. You have been asked to pay a $60 copayment for each radiation treatment. The total amount you owe is $120 ($60/treatment x 2 treatments = $120). Radiation treatments 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 radiation treatments provided on December 17, 2019 and December 18, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional therapy visits for the enrollee.You asked the Plan to pre-approve the additional visits. You say that this is medically necessary, as the enrollee is concerned about posture and losing height.The Plan denied your request. The Plan says continued services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no objective evidence of an orthopedic exam or progress note indicating that additional PT is needed for scoliosis. It is unclear why a physical therapist is performing LSVT with the enrollee rather than a speech therapist. There is insufficient evidence to support or refute the efficacy of any form of speech language therapy over another to treat speech problems in patients with Parkinson's Disease. The requested physical therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive prior physical therapy for her condition and should be able to transition to an independent home exercise program. Furthermore, in regards to LSVT, the literature does not support one form of speech therapy over another. The unique skills of a physical therapist are not indicated to provide treatment and the services do not require the supervision of a PT or OT. The specialized skill of a qualified therapist are not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. Medicare rules for coverage of the additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approve additional therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on September 4, 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 Healthcare Common Procedure Coding System (HCPCS) code J2920 (1 unit) remains 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 definition of HCPCS code J2920 is "injection, methylprednisolone sodium succinate, up to 40 mg." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the documentation indicates that on the DOS in question, the enrollee received injections of lidocaine and Orthovisc. There is no evidence that the enrollee received an injection of methylprednisolone. Therefore, the billing of CPT J2920 is not supported. 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 pay for injection services provided to the enrollee on September 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for Outpatient Mental Health services (90792) provided from September 19 to September 30, 2019. You asked the Plan to pay for the Outpatient Mental Health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider has opted out of the Medicare program and is ineligible for payment. The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that this provider has opted out of Medicare through September 1, 2021. Based on this information, we decided that Medicare rules for coverage of the Outpatient Mental Health services have not been met. Therefore, we decided that the Plan does not have to pay for Outpatient Mental Health services (90792) provided from September 19 to September 30, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing for 8-14 classes provided on August 22,
2019.
You asked the Plan to pay for the definitive drug testing. You say that the documentation is sufficient to
support payment. The Plan denied your request. The Plan says that The submitted Laboratory Requisition was
not signed by named ordering provider, or in lieu of a signed order, authenticated medical records (e.g., a
progress note) from the ordering provider documenting the treating physician had intended the clinical
diagnostic test be performed. Of note, the signed laboratory order is also missing the credentials for that reason
we cannot tell to whom the signature belongs.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by a
treating provider.
In this case, we find that the order clearly documents the intent to provide definitive testing on at least 14 drug
classes. Also, we find the Plan's rationale that there is no signature on this order AND that the electronic
signature does not have credentials so it is not known who provided the electronic signature to be invalid. The
electronic signature matches the name of the ordering provider listed on the claim and, in fact, is a network
provider with the health plan. The health plan would be able to verify with its network provider whether this
order was submitted and also could access the medical notes from that provider's office. Therefore, we decided
that the Plan has to pay for the definitive drug testing for 8-14 classes provided on August 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 14, 2019 to January 17, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the correct value code is not listed on the claim that was submitted.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include value code 85. Value code 85 is required for all claims submitted on bill type 032X with services furnished on or after January 1, 2019. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 14, 2019 to January 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on May 3, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 22855 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 22855 is removal of anterior instrumentation.
We find that CPT code 22855 is not supported in the medical record. Specifically, the documentation does not
include a detailed procedure note indicating that removal of anterior instrumentation was performed. 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 to the enrollee on May 3, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an electrocardiogram (93010) provided on July 7, 2019.
You asked the Plan to pay for the electrocardiogram. You say that the services were rendered prior to the
member's date of death. The Plan denied your request. The Plan says that the memeber's Plan was terminated
and not active on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that if not terminated sooner, coverage ends with the
beneficiary's death.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the electrocardiogram have been met. Specifically, the record indicates that the member's date of
death was July 12, 2019. This service was rendered prior to the member's date of death. Therefore, we decided
that the Plan has to pay for an electrocardiogram (93010) provided on July 7, 2019.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74178).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says that rules for coverage were not met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our reviewer says that the CT scan is medically necessary. Our physician reviewer found the enrollee had an MRI of abdomen demonstrating a renal lesion which required further investigation. The requested CT Scan of the abdomen and pelvis is medically reasonable and 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 CT scan have been met. Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74178).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home blood pressure monitor purchased on January 22, 2020.
You asked the Plan to reimburse you for the home blood pressure monitor. You say that your practitioner instructed you to monitor your blood pressure daily. The Plan denied your request. The Plan says you did not meet the medical necessity criteria.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to reimburse you for the home blood pressure monitor purchased on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 13, 2019 by an out of network (OON) provider. You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved for payment. 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 September 13, 2019 by an out of network (OON) provider.