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

We decided that the Plan does not have to pay for prosthetic management (97763) provided on November 15, 2018.You asked the Plan to pay for the prosthetic management. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was not submitted with the required modifier to process and pay 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 CPT code 97763 is not supported in the record. Specifically, CPT code 97763 is a therapy only code and must always be reported with the appropriate GN, GO or GP modifier.  Based on this information, we decided that Medicare rules for coverage of the prosthetic management have not been met. Therefore, we decided that the Plan does not have to pay for prosthetic management (97763) provided on November 15, 2018.
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 requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH). Initially admitted for scheduled knee surgery, the enrollee subsequently developed ARDS requiring intubation/ventilation. The enrollee has since received a tracheotomy and remains on a ventilator. The March 26 note provides contradictory information as to whether or not the enrollee is currently appropriate for ventilator weaning. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits and consultation for proton beam radiation therapy.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the evidence does not support any definitive benefit to proton beam therapy over IMRT in the treatment of prostate cancer.
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 the requested services. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT or IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials. Therefore, the requested services are not 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve office visits and consultation for proton beam radiation therapy.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee on October 25, 2018 to November 6, 2018.
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 claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that home health claims must be billed with the appropriate HHRG code. We looked at the file and Medicare rules. The claims were not billed with the correct HHRG code. 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 home health services rendered to the enrollee on October 25, 2018 to November 6, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided by EMS on October 5, 2019 and October 11, 2019.
You asked the Plan to waive the copayments for ambulance services. You say that you cannot afford the
charges because you were admitted to the hospital twice. 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 $200
copayment for ambulance services.
You received ambulance services on October 5, 2019 and October 11, 2019. Therefore, you are responsible to
pay a $200 copayment per each date of service. The total amount you owe is: $400.
You have been asked to pay the total copayment amount of $400 for ambulance services. Ambulance services
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 copayments for
ambulance services provided by EMS on October 5, 2019 and October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided to enrollee by an out of area (OOA) provider.You asked the Plan to pre-approve the OOA services. You say that the enrollee would benefit from a second opinion with one of the top pathologists in the world.The Plan denied your request. The Plan says the services are available within the network.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis 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. We found no exception that would require the Plan to pre-approve these OOA services. Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided to enrollee by an out of area (OOA) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services provided from May 1, 2018 to May 5, 2018. 
 
You asked the Plan to pay for the direct skilled nursing services. The Plan denied your request. The Plan says the information received did not show that the enrollee had a skilled nursing need for nursing home visits. The Plan also says that the nursing visits were not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit all documentation to confirm that Medicare coverage criteria have been met.   
 
We looked at the file and Medicare rules. The record shows that no documentation was submitted to support coverage of these services. Based on this information, we decided that Medicare rules for coverage of the direct skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services provided from May 1, 2018 to May 5, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on October 21, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.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 an independent laboratory; 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 forthe drug testing rendered on October 21, 2019.
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 it is necessary to go to an IRF because you were independent and active before going to the hospital and want to return to being independent.The Plan denied your request. The Plan says the guidelines for coverage have not been met.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 [state the medical finding(s) upon which the physician based his/her conclusion]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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that the enrollee's medical condition requires close supervision and she would benefit from daily therapy. The Plan denied your request. The Plan says the enrollee can get skilled care on a less than daily basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found The beneficiary was admitted to the hospital due to progressive leg weakness. She had a spinal fusion surgery in January then suffered a fall causing an L3 burst fracture. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. Regarding rehabilitation services, the beneficiary received PT and OT in the SNF. The beneficiary was at a moderate assist level with bed mobility and assist of 2 for transfers. The beneficiary required varying assist with ADLs. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, therapy is not required on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September
23, 2019 to September 30, 2019.
You asked the Plan to pay for SNF care. You say that the enrollee was not in hospice when these services were
rendered. The Plan denied your request. The Plan says coverage of these services is the responsibility of
Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on September 16, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for skilled nursing
facility (SNF) care provided from September 23, 2019 to September 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain crown for tooth #11.You asked the Plan to pre-approvea porcelain crown. You say that the tooth is causing constant pain.The Plan denied your request. The Plan says your benefit has been exhausted for the plan year.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. We looked at the file, and Medicare rules. The records show that the plan has already approved 2 crown procedures this calendar year. Your plan only covers 2 procedures per year. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approvea porcelain crown for tooth #11.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Orthovisc is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. The documentation does not show that the enrollee has tried and failed at least three months of conservative therapy. Injections of intraarticular hyaluronic acid are not widely recommended due to the lack of clear benefits over intraarticular placebo. Large, double-blinded studies indicate that intraarticular hyaluronic acid has a small, clinically irrelevant benefit over intraarticular placebo. Orthovisc is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy services rendered to the enrollee on July 30, 2019.

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 procedures code 96413 and 96415 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 96413 is chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. The definition of code 96415 is chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure).

We find that CPT codes 96413 and 96415 are not supported in the medical record. Specifically, the records do not include the start and stop time to indicate that chemotherapy administration for up to one hour was performed to support code 96413. Given that the primary code 96413 is not supported, the add-on code 96415 is also not supported. 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 chemotherapy services rendered to the enrollee on July 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora magnetic resonance imaging (MRI) of the brain (70553) and gadobutrol injection (A9585) provided on July 29, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe MRI of the brain and gadobutrol injection. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization, therefore coverage criteria has not been met.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 fora magnetic resonance imaging (MRI) of the brain (70553) and gadobutrol injection (A9585) provided on July 29, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 26, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
documentation submitted did not include a valid physician order/lab requisition or medical records stating
exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services provided on October 23, 2019. 
 
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on August 28, 2019.You asked the Plan to waive the copayment forthe endoscopy. You say that you cannot afford the copayment each time the test is done.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 $150 for each visit to an outpatient hospital facility.You have been asked to pay $150 for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe endoscopy provided on August 28, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy (45380) provided on September 19, 2019.You asked the Plan to waive the copayment for a colonoscopy with biopsy. You say that you were told you would not have to pay for this service.The Plan denied your request. The Plan says this service processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient surgery. You have been asked to pay a $295 copayment for a colonoscopy with biopsy. A colonoscopy with biopsy 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 a colonoscopy with biopsy (45380) provided on September 19, 2019.