Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home Prothrombin Time/International Normalized Ratio (PT/INR) testing (G0249) provided December 4, 2019 to December 16, 2019.
You asked the Plan to pay for the PT/INR testing. You say that you believe you are in compliance with the Medicare regulations for home PT/INR monitoring and that you have a valid treating physician order authorizing your service justifying medical necessity. The Plan denied your request. The Plan says the information submitted does not support this many/frequency of services.
The Plan must follow Medicare rules. Medicare rules say that providers must bill with the correct code to describe the services rendered. The rules also say that testing with the home PT/INR system should not be done more than once per week. In this case, the CPT Code Manual definition of code G0249 is Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare. Evidence was submitted showing that the provider billed G0249 on November 22,2019 and payment was made. However, provider billed same service for December 4,2019 and December 16, 2019. Per review services were billed for 12 billing days and 24 billing days, which are earlier than required 25 billing days. Based on this information, we decided that Medicare rules for coverage of the PT/INR testing have not been met. Therefore, we decided that the Plan does not have to pay for the home Prothrombin Time/International Normalized Ratio (PT/INR) testing (G0249) provided December 4, 2019 to December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 9, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy services; however, she does not require an intensive inpatient rehabilitation therapy program. Additionally, based on the records provided, there is concern that the enrollee will not be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent disease testing provided on February 10, 2020.You asked the Plan to pay for laboratory test. You say that you only perform this testing at your hospital laboratory.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.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 laboratory test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation submitted is insufficient to demonstrate that this testing was medically reasonable and 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 laboratory test have not been met.Therefore, we decided that the Plan does not have to pay for infectious agent disease testing provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and a breathing capacity test provided on January 8, 2020 and January 20, 2020.
You asked the Plan to waive the copayments for a specialist visit and a breathing capacity test. You say that you disagree with the charges because you have never been charged in the past. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $50 copayment for diagnostic procedures and tests. You had a specialist visit on January 8, 2020. Therefore, you are responsible to pay the $35 copayment. You received a breathing capacity test on January 20, 2020. Therefore, you are responsible to pay the allowed amount of $29.35, which is less than the $50 copayment. The total amount you owe is $64.35. You have been asked to pay the total copayment amount of $64.35 for a specialist visit and a breathing capacity test. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. A breathing capacity test falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayments for a specialist visit and a breathing capacity test provided on January 8, 2020 and January 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care (physical therapy and speech therapy).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the skills of a licensed physical therapist are no longer needed.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found there is no
indication that you are home-confined. Further, at this time the ongoing mobility deficits can be addressed at a
lesser level such as outpatient therapy or use of a home program. As such, the necessity for home health care
services is not substantiated. Therefore, this request is 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health care (physical therapy and speech therapy).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient substance abuse rehab.You asked the Plan to pre-approveinpatient substance abuse rehab. You say that the requested items/services are considered medically reasonable and necessary.The Plan denied your request. The Plan says the requested items/services are not considered medically reasonable and necessary in this case.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 inpatient substance abuse rehab. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the member was admitted/referred for substance abuse treatment. He had a history for atrial fibrillation, hypertension, hypothyroidism, congestive heart failure, and diabetes. He reported daily alcohol use. There is no report of current withdrawal symptoms, biomedical complications, abnormal laboratory results, suicidal ideation, homicidal ideation, psychosis, or assaultive/threatening behavior. He is hospitalized for withdrawal symptoms due to alcohol useIn this case, the review indicates that there is no evidence for withdrawal requiring acute management, barriers to change, dangerous environment, severe dysfunction in daily living, or danger to self or others that requires Residential level of care. The review has determined that the enrollee does not have a covered indication per the above NCD for the requested admission for Inpatient Substance Abuse Rehab starting June 24, 2020 and forward. The requested inpatient substance abuse rehab is not medically reasonable or necessary for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatientsubstance abuse rehab have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient substance abuse rehab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EKG provided on February 7, 2020.
You asked the Plan to waive the copayment for the EKG. You say that you have never been charged more than $7 or $8. You say that you don't agree with an $18 charge for a two minute test. The Plan denied your request. The Plan says the copayment applied 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 $25 copayment for Medicare-covered non-radiological diagnostic services. Examples include, but are not limited to EKG's, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests. You have been asked to pay $18.23, which is less than the standard $25 copayment for the EKG. The EKG falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the EKG provided on February 7, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for CPT 99053 provided on September 19, 2019.
You asked the Plan to pay for CPT 99053. The Plan denied your request. The Plan says that this code is
mutually exclusive to CPT 99291.
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. The plan indicates that CPT 99053 is not payable when billed with CPT 99291.
The plan has not provided documentation supporting this argument. CPT 99053 is not part of a Column
I/Column II edit pair with CPT 99291. Without supporting documentation, the plan's denial cannot be
substantiated. Therefore, we decided that the Plan has to pay for CPT 99053 provided on September 19, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a CGM. The
Plan denied your request. The Plan says the enrollee has not met criteria for a CGM.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. The record does not show the enrollee tests four or more times a day.
The record shows the enrollee is not insulin treated three or more times a day. Based on this information, we
decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we
decided that the Plan does not have to pre-approve continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on February 11, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Review of the file show that you received periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on February 11, 2020 by an out-of-network provider. Your EOC states, providers are paid based on Maximum Allowable Charge (MAC). For services covered under the plan, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider. Therefore, we decided that the Plan does not have to pay for periodic oral evaluation - established patient (D0120) and prophylaxis - adult (D1110) provided on February 11, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an inpatient rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that an 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 that your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not indicate that you have significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a skilled nursing facility. A less intensive, longer duration of therapy is appropriate. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires mid-to-long term acute care which the LTACH can provide.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physicianreviewer found the documentation does not support that the enrollee requires services at the LTACH that are not available in the acute care hospital setting where he is currently receiving care. Consequently, the requested LTACH services are not medicallynecessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1851) provided to the enrollee on July 12, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
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 a knee orthosis (L1851) provided to the enrollee on July 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 11 additional routine transportation miles.
You asked the Plan to pre-approve 11 additional routine transportation miles. You say that these doctors are specialists and you need back surgery. The only way to have surgery is to go see them and you need transportation to get there but the plan won't provide the other 11 miles. The Plan denied your request. The Plan says the request for an additional 11 miles (for a total of 86 miles) exceeds the benefit limitation. The plan contract says that each one-way trip must not exceed 75 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that this request exceeds the maximum benefit for coverage of routine transportation mileage. Therefore, we decided that the Plan does not have to pre-approve 11 additional routine transportation miles.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient clinic visit provided on December 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for outpatient clinic visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no in-network deficiency 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 outpatient clinic visit provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zovirax Ointment.
You asked the Plan to pre-approve Zovirax Ointment. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zovirax Ointment.