Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on July 18, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that you are contracted with the skilled nursing facility.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 forskilled nursing services provided on July 18, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2018.You asked the Plan to pay for the laboratory services. You say The Plan denied your request. The Plan says the enrollee was actively enrollee in hospice and the related charges are covered under traditional Medicare.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 19, 2018.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for intraoperative neuromonitoring provided by Evokes on July 22, 2019.You asked the Plan to pay for intraoperative neuromonitoring. You say that these services were requested by the enrollee's surgeon and performed at an in-network facility.The Plan denied your request. The Plan says that the denial of payment for these services is correct.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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.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 specify whether the ordering physician or the servicing facility are in-network or out-of-network with the Plan. The documentation does not show that prior notice was given that these services would not be covered. Without this information, we cannot determine whether the order for intraoperative neuromonitoring constituted plan-directed care. Therefore, the Plan has not shown that their decision to deny payment for these services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay forintraoperative neuromonitoring provided by Evokes on July 22, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on February 14, 2019.You asked the Plan to pay for the drug test.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 a drug test provided on February 14, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on April 18, 2019.You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the ambulance service did not meet criteria.The Plan must follow Medicare rules. The rules state that providers must report services correctly.In this case, the provider submitted their claim for payment with a GY modifier that indicates that the services provided were non-emergent.  Because the provider is out of network, the plan cannot over-ride the claim. Non-emergent ambulance transport is not a covered service. Based on this information, we decided that Medicare rules for coverage of ambulance services,billed with a GY modifier,have not been met.Therefore, we decided that the Plan does not have to pay for services provided on April 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip orthosis and addition provided by Global DME on August 16, 2019.You asked the Plan to pay for the hip orthosis (L1686), and addition (L2624). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.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 the hip orthosis and addition provided by Global DME on August 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on October 12, 2019.You asked the Planto pay forthe ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at this the file and Medicare rules. The record shows the enrollee, complaining of anxiety was conscious, stable, in no acute respiratory or cardiac distress and had no sign of injury, stroke, or hemorrhage. Neither oxygen nor emergency treatment was needed for transport.Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forservices provided on October 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on September 18, 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 to you by an out-of-network provider on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 29, 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 claim to be reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are multiple in-network providers available 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 July 29, 2019 by an out of network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you feel that without intensive daily therapy of three hours or more, you are not going to be able to learn how to use your new prosthesis safely.The Plan denied your request. The Plan says you are medically stable and do not require acute medical care in the hospital setting.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 the enrollee underwent a right above-the-knee amputation in 2019. She had been doing well until recently, when she was given a new prosthesis. She was fitted with a C-leg micro-processor. She is able to take 2 steps. She also moved to a new home with bedroom upstairs and now needs stair training. She fell one week ago without injury. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's current medical status requires the intensity of an IRF stay with close physician or nursing supervision.The patient may benefit and participate in additional therapy of PT and OT but the patient does not require this on an intensive rehabilitation facility therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea foot massager.You asked the Plan to pre-approvea foot massager. You say that you have neuropathy and feela foot massage machine will help you.The Plan denied your request. The Plan says foot massagers are not covered by Medicare or the Plan.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-approvea foot massager.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the abdomen.You asked the Plan to pre-approve the MRI. You say that this is medically necessary.The Plan denied your request. The Plan says that based on the notes, this cannot be approved.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI medically reasonable and necessary. Our physician reviewer found the presence of such dilatation of the common bile duct and pancreatic duct is worrisome for cholangiocarcinoma, ampullary tumor or tumor in the pancreatic uncinate process. Other possibility would be distal common bile duct stricture or stone. The best imaging tests to evaluate for these potential diseases is MRI and MRCP. The request is reasonable, medically necessary and should be approved.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 MRI have been met.Therefore, we decided that the Plan has to pre-approve MRI of the abdomen.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on November 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you are contracted with the skilled nursing facility. The Plan denied your request. The Plan says the referring provider is out-of-network. 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 lab services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulatory blood pressure monitor (A4670) provided on October 24, 2019.You asked the Plan to pay for the ambulatory blood pressure monitor. You say that this was medically necessary.The Plan denied your request. The Plan says coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that ABPM must be performed for at least 24 hours to meet coverage criteria and is only covered for those patients with suspected white coat hypertension.We looked at the file and Medicare rules. In this instance, there is no evidence of a diagnosis of white coat hypertension, or monitoring for at least 24 hours. Based on this information, we decided that Medicare rules for coverage of the ambulatory blood pressure monitor have not been met.Therefore, we decided that the Plan does not have to pay for an ambulatory blood pressure monitor (A4670) provided on October 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says there is no information given indicating the need for a chest CT scan.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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee is almost 8 years post diagnosis and treatment and shows no clinical or imaging evidence of metastasis/recurrence. His original disease was discovered in the abdomen and there has been no history of thoracic involvement. NCCN guidelines support CT scanning when there is clinical evidence to suggest recurrence. This enrollee has no clinical evidence of same.There are no recent plain chest x-ray results which require CT scanning for clarification.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 scan have not been met.Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (96413, 96417, 96375) provided on October 21, 2019 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.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 96413 is "Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug". The CPT Code Manual definition of code 96417 is "Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 96375 "Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)". We asked our coding 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 use of CPT codes 96413, 96417, 96375, is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of a start or stop time for Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug, therefore CPT 96413 cannot be verified. The medical records provided did not include a start and stop time of the infusion, therefore CPT 96417 cannot be verified. CPT code 96375 is an add-on code and requires the primary procedure to be eligible for reimbursement. In this case, CPT code 96413, the primary procedure, did not meet criteria for reimbursement, therefore CPT code 96375 is not eligible for reimbursement. We looked at this coder'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 the services (96413, 96417, 96375) provided on October 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot surgical procedure provided on August 15, 2019 billed with CPT code 27759.You asked the Plan to pay for the ankle/foot procedure. You say that the claim was correctly coded to describe the services rendered.The Plan denied your request. The Plan says the code was not supported in the medical records.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 27759 is Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage.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 ankle/foot procedure. Our reviewer says that the documentation does not support the billed code. Our physician reviewer found while a rod was placed through the enrollee's tibia, this rod was not placed to treat a tibial fracture. The rod was placed to stabilize the enrollee's ankle and did indeed span the ankle joint. As such, the billing of CPT 27759 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 ankle/foot procedure have not been met.Therefore, we decided that the Plan does not have to pay for the ankle/foot surgical procedure provided on August 15,2019 billed with CPT code 27759.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on September 28, 2018.You asked the Plan to pay fortheservices. The Plan denied your request. The Plan says the claim was filed after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until October 3, 2019.. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decidedthat the Plan does not have to pay forthe services provided on September 28, 2018.