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

We decided that the Plan does not have to pay for tissue exams by a pathologist (88304, 88305) provided on
March 31, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for pathology exams. You say that the provider took the specimen at their office and
sent them to our laboratory for analysis. The Plan denied your request. The Plan says that the provider at issue
is not contracted with the Plan for medical services, there was no authorization on file and no referring
provider.

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 had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. The records provided for review do not show that the services at issue were urgent or
emergent. 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 tissue exams by a pathologist (88304, 88305) provided on March
31, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are needed to the improve the
enrollee's pain. The Plan denied your request. The Plan says that there is no documentation of recent physical
therapy.

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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no documentation 
of adequate conservative measures for back pain to include physical therapy. The cause of the back pain is not clear 
in this case. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve sacroiliac joint arthrodesis for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance transports you received on January 25, 2020, and April 30, 2020.

You asked the Plan to waive the copayments for the ambulance transports. You say that you were admitted to the hospital on both of these occasions, so the copayments should be waived. The Plan denied your request. The Plan says you were charged these copayments 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 $250 copayment for each ambulance trip. 

You have been asked to pay a $250 copayment for each of the ambulance transports. There is no provision in your contract permitting waivers of these copayments if you are admitted to the hospital. 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 copayments for ambulance transports you received on January 25, 2020, and April 30, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy sessions provided on February 15 to March 15, 2021, by a provider who has opted out of Medicare.

You asked the Plan to pay for psychotherapy sessions. You say that the Plan's alternative providers do not have the same qualifications as the provider at issue in this case. The Plan denied your request. The Plan says rules for payment have not been met because the provider at issue has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy sessions provided on February 15 to March 15, 2021, by a provider who has opted out of Medicare.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient Part B hospital services provided from November 8, 2020, through November 9, 2020.

You asked the Plan to pay for the inpatient Part B services. You say that a no-pay inpatient claim was submitted with Type of Bill 0110. This claim is for the Part B-covered services provided during the noncovered inpatient hospital stay. This has been billed correctly. The Plan denied your request. The Plan says that as no inpatient-only services were billed and the non-participating facility billed with a Type of Bill for Part B inpatient services, no payment can be made.

The Plan must follow Medicare rules. Medicare rules say that inpatient Part B may be paid when Part A coverage is not allowed. These services must be report on Type of Bill 012X. 

The Plan's denial rationale in this case is not appropriate. The facility correctly submitted a no-pay inpatient Part A claim, and then submitted this inpatient Part B claim for payment of the inpatient ancillary services that are payable by Part B. The Plan does not provide a cogent reason that this claim cannot be paid. Therefore, we decided that the Plan has to pay for the inpatient Part B hospital services provided from November 8, 2020, through November 9, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70470) provided on February 24, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable.

The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 70470 is part of an edit pair with procedure code 70496. Procedure code 70496 is a column one code, and procedure code 70470 is a column two code. Procedure code 70496 has been paid for this date of service, which means that procedure code 70470 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (70470) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for infusion drugs you received from March 17, 2021, to March 23, 2021.
You asked the Plan to waive the coinsurance for the infusion drugs. You say that you feel as though your coinsurance is too high. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the infusion drugs. The infusion drugs fall within the Medicare Part B drugs 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 coinsurance for infusion drugs you received from March 17, 2021, to March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 15, 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 services are not covered.

The Plan must follow Medicare rules. Medicare rules say that next generation sequencing (NGS) is covered when specific criteria are met. 

We looked at the file and Medicare rules. There are no submitted medical records to support that the criteria for coverage of the NGS testing are met. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 15, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95912, 95886, 95999) provided on April 20, 2020.

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 95912 is "Nerve conduction studies; 11-12 studies". The CPT Code Manual definition of code 95886 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure". 

We asked our coder 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 codes 95912, 95886, and 95999 is not supported by the records provided. Our reviewer found that for CPT 95912, the procedure report documents "Pedicle screw stimulation" and does not include nerve conduction studies. Therefore, this procedure cannot be confirmed as performed. For CPT 95886, the procedure report does not include documentation of a nerve conduction study, which is included in this procedure, therefore, this service would not be covered. For CPT 95999, the procedure report does not include documentation of an unlisted procedure. The procedure report represents Train of Four is being reported with this CPT code. Train of Four is inclusive to intraoperative neurophysiological monitoring and would not be separately reported. 

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 (95912, 95886, 95999) provided on April 20, 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 that you are not yet ready to go home. The Plan denied your request. The Plan says that no skilled nursing needs or skilled therapy needs are identified that require the requested level of care.

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 have a history of chronic lymphocytic leukemia, congestive heart failure, diabetes, asthma and are living in a nursing facility with ongoing weakness and trouble ambulating. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis (74178) and a CTA scan of the chest (71275).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and a CTA scan of the chest. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested imaging services are not medically necessary.
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 a CT scan of the abdomen and pelvis and a CTA scan of the chest. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that there is no role for a follow-up CT of the chest to assess a pulmonary embolus or for a CT scan of the abdomen and pelvis to assess a liver lesion.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the abdomen and pelvis and a CTA scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis (74178) and a CTA scan of the chest (71275).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the skills of a physical therapist are not required to continue to treat the enrollee.
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 additional services. Our physician reviewer found that the additional requested therapy is not generally accepted as effective therapy for the enrollee's condition beyond what was approved by the Plan.
The records do not demonstrate that the unique skills of a professional therapist are required provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. The documentation does not reveal significant deficits on the right knee that require additional supervised therapy. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist is not required to establish a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 15, 2021, to March 18, 2021.

You asked the Plan to pay for the home health services. You say that these services should be paid. The Plan denied your request. The Plan says the home health services provided were not submitted on a valid TOB.

The Plan must follow Medicare rules. Medicare rules say that possible TOB for home health claims are either 0322, 0327, 0328, or 0329. 

This claim was reported with a TOB of 0324. This is not a valid TOB for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the home health services provided from March 15, 2021, to March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 5, 2021.
You asked the Plan to pay for the services. You say that the enrollee was treated by an in-network provider, and the billed tests were performed at the request of the referring physician. The Plan denied your request. The Plan says the services were not supported by the procedure codes billed on the claim.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on January 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance service, basic life support, nonemergency
transport provided on February 10, 2021.
You asked the Plan to waive the copayment for the ambulance service. The Plan denied your request. The Plan
says cost sharing is a contractual obligation under the plan and cannot be waived.
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 $250
copayment for ambulance services.
You have been asked to pay a $250 copayment for the ambulance service. The ambulance service falls within
the ambulance services 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 ambulance
service, basic life support, non-emergency transport provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 7, 2020.

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 denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.

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 requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the obtained laboratory studies. The review has determined the laboratory services provided to the enrollee on December 7, 2020 were not medically necessary or reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 7, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90832) rendered by the out-of-network
(OON) provider on October 8, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the psychotherapy (90832) rendered
by the out-of-network (OON) provider on October 8, 2020.