Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on August 3, 2020.

You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an incorrect POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The record shows that the service at issue was billed with POS 81 for an independent laboratory, but the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on August 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 2, 2020.

You asked the Plan to pay for the laboratory 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 laboratory 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 laboratory services provided on December 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this transportation to see your oncologist. The Plan denied your request. The Plan says that your request exceeds the benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits, they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency department services (99284) provided on August 9, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says that there was no
documentation/signature submitted for a provider affiliated with the billing group.
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. Specifically, the Plan has failed to forward a claim to verify who the rendering
provider is and if they are affiliated with the billing provider. It is the burden of the Health Plan to substantiate
their denial with evidence. The denial is not substantiated, and we must find in your favor. Therefore, we
decided that the Plan has to pay for emergency department services (99284) provided on August 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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).

You asked the Plan to pre-approve the wheelchair power seat elevation system. You say that you would like the Plan to cover this item. The Plan denied your request. The Plan says although most of the equipment can be approved, the power seat elevation system is statutorily not covered.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is not a covered item because it is not primarily medical in nature.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the wheelchair power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fifteen (15) physical therapy visits to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you are requesting to get the services from this provider because you went to them for help for many years. The Plan denied your request. The Plan says this provider is not in your 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. Therefore, we decided that the Plan does not have to pre-approve fifteen (15) physical therapy visits to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

You asked the Plan to pre-approve 5 additional visits of day institute therapies. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 5 additional visits of day institute
therapies. 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 the enrollee is on a regular diet without
signs of aspiration. The enrollee's speech is 100 percent intelligible. The enrollee's deficits do not require the
ongoing professional skills of a speech therapist. The enrollee's functional level does not require the ongoing
skills of a physical therapist. The enrollee may benefit from occupational therapy sessions to review use of the

Saebo MAS and wrist support once it is available for the enrollee, but this does not need to be in a Day Institute
setting. Ongoing physical therapy, occupational therapy, and speech therapy in a Day Institute program would
not be considered specific and effective for the enrollee's needs. The enrollee's needs can be met at a lower
level of care and a home exercise program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 5 additional visits of day institute therapies have not been met. Therefore, we
decided that the Plan does not have to pre-approve 5 additional visits of day institute therapies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on October 23,
2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you should not owe a copayment
for laboratory services. 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 $10
copayment for laboratory tests.
You have been asked to pay the allowed amount of $3, which is less than the $10 copayment for laboratory
tests. Laboratory tests 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 tests provided on October 23, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Posterior Cervical Decompression surgery (93045, 63015, 63048,
63001) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that that there is no medical necessity as no formal exhaustive
conservative routes are noted.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. This enrollee is being
treated for spondylosis with radiculopathy of the cervical region. She noted a 1-year history of severe right
upper extremity pain. She awoke one morning with increased cervical pain and new pain radiating down the
right upper extremity. The pain was described as a 10/10 at the time. There is numbness/weakness in the hands
and fingers. Exam revealed reflexes are symmetrically hyporeflexic in the upper and lower extremities. X-rays
demonstrated severe disc space narrowing at C4-5, C5-6, C6-7, and C7-T1, moderate endplate productive
changes at multiple levels. MRI demonstrated multilevel stepladder anterolisthesis at the C3-C4 and the C4-C5
levels with focal kyphosis at the C4-C5 level resulting in mild spinal canal narrowing. There is broad-based
disc herniation with mild spinal canal stenosis is seen at the C5-C6, C6-C7, and C7-T1 levels. Enrollee was
treated with a course of conservative treatment (which has included over 40 sessions of physical therapy,
cervical epidural steroid injection, chiropractic manipulation, and multiple medications including prednisone,
hydrocodone, and gabapentin without relief).

Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging
studies. Trial and failure of extensive and reasonable conservative treatment modalities has been well
documented. Our physician reviewer found that the enrollee's condition meets criteria for coverage of these
services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove
Posterior Cervical Decompression surgery (93045, 63015, 63048, 63001) for the enrollee.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Donepezil for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. 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 Donepezil for the enrollee.
Benefits for this drug 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 pay for the chemotherapy services rendered on July 17, 2020.

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 claim has not been processed by the primary insurer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan confirmed that the enrollee had primary insurance with a different Plan for the date of service at issue. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the chemotherapy services rendered on July 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on July 30, 2020.
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 G0482 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; 15-21
drug class(es), including metabolite(s) if performed.
We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service
on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81;
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained
in an office setting place of service 11. 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 G0482 provided on July 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on August 2, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place then triaged to BLS. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 2, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on August 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-area physical therapy services.

You asked the Plan to pre-approve out-of-area services. You say that the enrollee has yet to reach maximal improvement. The Plan denied your request. The Plan says the services are no longer urgent, emergent or unforeseen.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 

We looked at the file, and Medicare rules. The requested services are not urgent. There is no indication the enrollee cannot get services from an in-network provider. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-area physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration services
coded 99601 and 99602 provided on July 26, 2020.
You asked the Plan to pay for the home infusion/specialty drug administration services. 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 providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 99601 and 99602 are not supported in the medical record. Specifically, these codes
have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes.
Medicare uses another code for reporting of, and payment of these services. Based on this information, we
decided that Medicare rules for coverage of the home infusion/specialty drug administration services have not
been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug
administration services coded 99601 and 99602 provided on July 26, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 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 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a light kit (K0108).
You asked the Plan to pre-approve a light kit. You say that this is necessary for the enrollee to go safely in the dark. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a light kit (K0108).