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

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 7, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that you needed an ambulance due to shortness of breath and the ambulance came but did not transport you because your breathing was getting better. The Plan denied your request. The Plan says Medicare rules state ambulance services are not covered when there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
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 ambulance response and treatment, no transport. Our reviewer says that ambulance response and treatment, no transport does not meet Medicare coverage criteria. Our physician reviewer found that you reported shortness of breath with chest pain. On the arrival of emergency medical services (EMS) you reported having these symptoms for three (3) days and that
this had happened in the past. You were given supplemental oxygen, which helped. You refused to go to the emergency room (ER) and preferred to use your home CPAP if you felt worse. You were not transported. Based on the provided records you refused transport and therefore, would not meet the CMS "treat in place" COVID-19 protocols for medically necessary ambulance transportation.
The ambulance company did not provide transport services on May 7, 2021. 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 ambulance response and treatment, no transport (A0998) provided on May 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are medically stable and have been provided medical clearance to undergo a total glenohumeral joint arthroplasty. The planned procedure is not listed on the Centers for Medicare & Medicaid Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not meet criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography of the thorax (71250) provided on March 17, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $50 copayment for Medicare-covered diagnostic radiology services. 

You have been asked to pay a $50 copayment for the Medicare-covered diagnostic radiology service provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.

This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography of the thorax (71250) provided on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 22,
2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were not advised you would
be billed for the service. The Plan denied your request. The Plan says you were charged this copayment
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 $200
copayment for Outpatient Surgery.
You have been asked to pay $200 copayment for the colonoscopy. The colonoscopy falls within the 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 the colonoscopy provided
on January 22, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an infected diabetic foot ulcer and had a below the knee amputation. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the therapeutic activities (97530), neuromuscular reeducation (97112) and physical performance test (97750) provided on March 11, 2021.

You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the 2 codes 97530 and 97750 conflict with each other and have to be billed using a modifier.

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 citation or evidence as to why these services are not supported. While CPT codes 97530 and 97750 are subject to National Correct Coding Initiative Edits, this code set is allowed a modifier. The documentation submitted shows that CPT code 97750 was billed with modifier 59, indicating that this was a separate and distinct service and offsetting the NCCI edit. Additionally, for NCCI edits to be applied, the column I code would need to be paid. It is inappropriate for bundling rules to be applied in this case. It is the burden of the Health Plan to substantiate their denial with evidence. The Health Plan has not substantiated their denial so we must find in your favor. Therefore, we decided that the Plan has to pay for the therapeutic activities (97530), neuromuscular reeducation (97112) and physical performance test (97750) provided on March 11, 2021.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care services provided from
December 31, 2020, through January 10, 2021.
You asked the Plan to pay for the inpatient mental health care services. The Plan denied your request. The Plan
says that the enrollee exhausted his covered 90 days inpatient admission on June 26, 2020. The enrollee was
admitted to different facilities between January 26, 2019 to May 11, 2019 and beyond with no gap of 60 days
between each hospitalization. Prior to the enrollee's admission to this hospital, the Plan covered 122 days of
inpatient mental health care services the enrollee received at numerous different hospitals the enrollee
exhausted his maximum benefit of 90 days per admission of inpatient mental health care, thus, the denial for
payment is upheld.
The Plan contract says the Plan covers 90 days for an inpatient hospital stay. The Plan also covers 60 "lifetime
reserve days." These are "extra" days that the Plan covers. If your hospital stay is longer than 90 days, you can
use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be
limited to 90 days.
We looked at the file and the Plan's rules. The file shows that the enrollee has exhausted the inpatient benefit.
Therefore, we decided that the Plan does not have to pay for inpatient mental health care services provided
from December 31, 2020, through January 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport, (A0429) provided on October 24, 2020.

You asked the Plan to pay for ambulance service, basic life support, emergency transport, (A0429). You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ambulance service, basic life support, emergency transport, (A0429). Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the enrollee is a 67-year-old female who was transported via ambulance from her residence to the hospital related to report of nausea, diarrhea, occasional cough, and fatigue since that same day in the morning. Emergency medical services (EMS) found the enrollee in chair breathing normally with airway patent. The enrollee's vitals were stable except for oxygen saturation 87-91% RA. The enrollee refused oxygen supplementation and was transported without treatment or issues. The enrollee's presenting symptoms did not meet prudent layperson criteria for emergency care. Other means of transport were not contraindicated for this enrollee since she did not use oxygen during transport. The documentation did not show that the enrollee required expertise or special equipment during transport. Therefore, the ambulance services will be considered not medically 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 ambulance service, basic life support, emergency transport, (A0429) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport, (A0429) provided on October 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a positron emission tomography (PET) scan (78815)
provided on July 21, 2020.

You asked the Plan to pay for a PET scan. You say that this was medically necessary. The Plan denied your
request. The Plan says this was not billed with an appropriate diagnosis.

The Plan must follow Medicare rules. Medicare rules say that PET scans must be billed with an appropriate
diagnosis code.

We looked at the file and Medicare rules. The billed diagnosis code, C67.9, is not listed as an appropriate code.
Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met.

Therefore, we decided that the Plan does not have to pay for a positron emission tomography (PET) scan
(78815) provided on July 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided December 22, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 code G0483 is not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology visit provided on November 2, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the oncology visit. You say that you should not be responsible for this claim. The Plan denied your request. The Plan says 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 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 oncology visit provided on November 2, 2020 by an out-of-network (OON) provider.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 your medical conditions are stable and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 24, 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 was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction of premalignant lesions (17000) provided on May 6, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that she must pay a $40 copayment for provider and professional services rendered at an in-network specialist's office.

The enrollee has been asked to pay a $40 copayment for the provider services rendered at a specialist's office. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the destruction of premalignant lesions (17000) provided on May 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).

You asked the Plan to pre-approve Hyalgan. You say that the Hyalgan is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Hyalgan. Our reviewer says that Hyalgan is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for glycosylated hemoglobin testing (83036) provided on February 3, 2021.

You asked the Plan to pay for glycosylated hemoglobin testing. You say that this test was billed correctly and is supported by the diagnosis. The Plan denied your request. The Plan says this test is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that glycated hemoglobin/protein testing is widely accepted as medically necessary for the management and control of diabetes. It is also valuable to assess hyperglycemia, a history of hyperglycemia or dangerous hypoglycemia.

We looked at the file and Medicare rules. The records do not show that the enrollee has diabetes, hyperglycemia, or hypoglycemia. Based on this information, we decided that Medicare rules for coverage of glycosylated hemoglobin testing have not been met. Therefore, we decided that the Plan does not have to pay for glycosylated hemoglobin testing (83036) provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on March 15, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the evaluation and management services. You say that the services were medically necessary and billed in error. The Plan denied your request. The Plan says the claim originally denied for not meet coding standards, but 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 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 evaluation and management services provided on March 15, 2021 by an out-of-network (OON) provider.