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

We decided that the Plan does not have to pay for the medical services provided on August 1, 2019
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent and there were in-network providers who could render these services. There was no preauthorization.
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 August 1, 2019
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient mental health care provided to the enrollee from July 23, 2019 through August 9, 2019.You asked the Plan to pay forinpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patientrequires 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 pay for inpatient mental health care. Our physician reviewer found based upon review the records provided it was expected this enrollee would improve in a reasonable period of time as although he did not have dangerousness to self or others, this patient did have auditory and visual hallucinations and was showing behavioral issues. It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as although he did not have dangerousness to self or others, he did have perceptualdisturbance including auditory or visual hallucinations.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 been met.Therefore, we decided that the Plan has to pay forinpatient mental health care provided to the enrollee from July 23, 2019 through August 9, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neuropsychological testing (CPT 96116, CPT 96132).
You asked the Plan to pre-approve the testing. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is covered when the above criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the requested neuropsychological testing is not medically reasonable and necessary. Our physician reviewer found that the documentation shows a decline in memory and other aspects of cognition according to the enrollee's physician. Utilizing the criteria from LCD L33632 showing the medical necessity consideration for neuropsychological assessment, the testing is used to find neurologic disease based on quantitative assessment of neurocognitive abilities i.e. mild head injury, anoxic injuries, aids or dementia. It is used to delineate neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders and or an assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. It does not appear that this enrollee meets the criteria, therefore it does not appear medically necessary or reasonable to have neuropsychological testing as outlined, as this enrollee complains of declining memory and cognitive decline, which is being called amnesia for this enrollee.
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 testing have been met. Therefore, we decided that the Plan does not have to pre-approve Neuropsychological testing (CPT 96116, CPT 96132).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forphysician services provided to the enrollee on September 20, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere was no valid referral for this service.Medicare rulessay 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 Plandoes not haveto pay forphysician services provided to the enrollee on September 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve C3-5 spinal fusion surgery (22551, 22552, 20936,
20930, 69900, 77003, 22845, and 22853).
You asked the Plan to pre-approve spinal fusion surgery. You say that you need this surgery because your pain
is unbearable. The Plan denied your request. The Plan says there is not evidence that your spinal nerves are
injured.
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 spinal fusion surgery. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the records do not show spinal instability. The requested surgery is not indicated 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan
does not have to pre-approve C3-5 spinal fusion surgery (22551, 22552, 20936, 20930, 69900, 77003, 22845,
and 22853).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on September 10, 2019
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that no prior authorization was 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 for physical therapy provided on September 10, 2019
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveofficeservices to be provided by "the provider (MFT)".You asked the Plan to pre-approveoffice services. You say that you have been seeing this provider for over a year and do not want to switch providers.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is not eligible to participate in Medicare and is not covered.The Plan must follow Medicare rules. Medicare rules say that Marriage and Family Therapists (MFTs) are not eligible to participate in Medicare and are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of office services have not been met.Therefore, we decided that the Plan does not have to pre-approveoffice services to be provided by "the provider (MFT)".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygenator assembly and operation services (CPT 99190)
provide to the enrollee on August 2, 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 denied code 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 CPT Code Manual definition of code 99190 is "Assembly and operation of pump with
oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour."
We find that CPT code 99190 is not supported in the medical record. Specifically, the payment for the code is
included in the payment to the facility. 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 oxygenator
assembly and operation services (CPT 99190) provide to the enrollee on August 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services provided to the enrollee on August 26, 2019.You asked the Planto pay forthe services. You say that lab services provided to the enrollee on August 26, 2019.The Plandenied your request. The PlansaysMedicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the documentation in the case file does not support that the laboratory testing in this case was medically reasonable and necessary for the care of the enrollee. It has not been demonstrated how this testing would impact her medical management. 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 Plandoes not haveto pay forlab services provided to the enrollee on August 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services provided to the enrollee on September 23, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says HCPCS G0483 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 code.In this case, the definition of HCPCS 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 drug-specific 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 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 based on the records provided, the code HCPCS G0483 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 serviceshave not been met.Therefore, we decided that the Plan does not have to pay fordrug testing services provided to the enrollee on September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 4, 2019 by the out of network provider.You asked the Plan to pay forlaboratory testing. You say that this test was ordered to obtain medically necessary information.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.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 September 4, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on April 3, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCurrent Procedural Terminology (CPT) code 80307 and HCPS G0482 code remain not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report serviceswith the appropriate CPT or HCPCS code.We find that the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0482) provided to the enrollee on April 3, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient stay provided from September 2, 2019 through September 6, 2019.
You asked the Plan to pay for the inpatient stay. You say that the admission is outside of the hospice range. You say that the claim should be reprocessed. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 2, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient stay provided from September 2, 2019 through September 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with a polyp removal
(45385) provided on August 8, 2019.
You asked the Plan to waive the copayment for a colonoscopy with a polyp removal. You say that this should
be covered. The Plan denied your request. The Plan says this processed 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 $395
copayment for Medicare-covered outpatient surgery, and that colonoscopies with polyp removals are subject to
outpatient surgery cost sharing.
You have been asked to pay a $395 copayment for a colonoscopy with a polyp removal. A colonoscopy with a
polyp removal falls within the Medicare-covered outpatient surgery 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 a colonoscopy with a polyp removal (45385) provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided to the enrollee on August 21, 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 Medicare says non-urgent services should be from network providers who are contracted with the healthplan and listed in the Provider Directory.
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 injection services provided to the enrollee on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-ofnetwork
provider on October 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. 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 medical services provided by an out-of-network provider on
October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on June 17, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on June 17, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) and attendant
control (E2331).
You asked the Plan to pre-approve a power seat elevation system and attendant control. 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 follows Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition
to a beneficiary-operated drive control system, it will be denied as non-covered and a power seat elevation
feature (E2300) and power standing feature (E2301) are non-covered because they are 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 a power seat elevation system and attendant control have not been met. Therefore, we decided that
the Plan does not have to pre-approve a power seat elevation system (E2300) and attendant control (E2331).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 8, 2019
You asked the Plan to pay for office visit. You say that you are appealing based on medical necessity. 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 for the medical services provided on July 8, 2019