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

We decided that the Plan does not have to pay for laboratory services provided on May 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that this was for a follow-up. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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. 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 laboratory services provided on May 25, 2021 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 inpatient rehabilitation is necessary for your recovery. The Plan denied your request. The Plan says the criteria for an IRF are not met and the necessary care can be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 10, 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 were 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 laboratory
services rendered on September 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from January 8, 2021 to January 14, 2021.
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. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from January 8, 2021 to January 14, 2021.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for arthroplasty, an X-ray and does not have to waive the coinsurance for a joint device provided on October 2, 2020.
You asked the Plan to waive the copayments for arthroplasty, an X-ray and to waive the coinsurance for a joint device. You say that you do not understand why the device is not being covered. 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 $50 copayment for outpatient surgery services provided at an outpatient hospital facility. Your contract with the Plan also clearly says that you must pay a $10 copayment for X-rays. Your contract with the Plan also clearly says that you must pay 20% coinsurance for prosthetic devices and related supplies. You received arthroplasty on October 2, 2020, at an outpatient hospital facility. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $50 copayment. You received an X-ray on October 2, 2020. Therefore, you are responsible to pay the $10 copayment. You received a joint device on October 2, 2020. The total allowed amount is $4,364.99 and 20% of that is $873. The total amount you owe is: $933. You have been asked to pay the total amount of $933 for arthroplasty, an X-ray and a joint device. Arthroplasty falls within the outpatient hospital services benefit category. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A joint device falls within the prosthetic devices and related 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 arthroplasty, an X-ray and does not have to waive the coinsurance for a joint device provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on May 19, 2021.
You asked the Plan to waive the copayment for an EGD. You say that there is no other location for you to receive the services. 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 $345 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received an EGD at an outpatient hospital facility on May 19, 2021. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $345 copayment.
You have been asked to pay a $345 copayment for an EGD. An EGD 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 for an EGD provided on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the present setting where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that the enrollee is in pain and is unable to move her arm. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy is correct, because the enrollee does not meet the criteria for additional therapy beyond what the Plan approved.
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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what the Plan approved. The enrollee has had prior therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, and that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. The enrollee has been instructed in a home exercise program and her functional deficits are not so significant that she requires ongoing therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AV node ablation and pacemaker implantation.
You asked the Plan to pre-approve these services. You say that you have been hospitalized three different times for these issues and you need these services. The Plan denied your request. The Plan says that there does not appear to be a medical indication for these services.
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. You have a medical history of coronary artery disease, congestive heart failure, peripheral vascular disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, gastrointestinal bleeding, and Crohn's disease. You were hospitalized from July 9, 2021 through July 19, 2021. Your heart rate rose to 110 - 150s on July 10, 2021. You were treated with amiodarone and digoxin. You had good rate control at the time of discharge, with a heart rate of 75. You do not have documented non-reversible symptomatic bradycardia due to sinus node dysfunction, or non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block. You do not have a covered indication for pacemaker implantation. The documentation does not support that you have failed pharmacologic rate control. Our physician reviewer found that your 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 AV node ablation and pacemaker implantation.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion drug administration (99601) provided on January 25, 2021.
You asked the Plan to pay for the home infusion drug administration. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99601 has a status indicator of I and is not valid for Medicare purposes.
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 99601 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99601 has a status indicator of I. This means that CPT code 99601 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion drug administration have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion drug administration (99601) provided on January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (PVA) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the requested procedure will exceed the allowed limit of three levels of the spine.
The Plan must follow Medicare rules. Medicare rules say that PVA is covered if LCD 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 requested services are not considered medically reasonable and necessary in this case. There is no documentation of osteoporosis management. The plan calls for more than 3 levels of vertebroplasty which exceeds the allowed number of levels. Most importantly, recent literature shows that vertebroplasty is not more effective than sham treatment for compression fractures. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 percutaneous vertebral augmentation (PVA) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the cancer screening services (G0101, Q0091) provided on January 19, 2021.
You asked the Plan to provide additional reimbursement for the cancer screening services. You say that you would like reconsideration because you are owed additional reimbursement for the services rendered. The Plan denied your request. The Plan says the appropriate coinsurance has been applied.
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 40% coinsurance for Cervical and Vaginal Cancer Screening. The Plan reimbursed you $227.40 for the billed services. The allowed amount for these services is $379. 40% of $379 is $151.60. $379 - $151.60 = $227.40. The Plan has reimbursed you the correct amount per the EOC.
You have been asked to pay $151.60 for the cancer screening services. the cancer screening services fall within the Cervical and Vaginal Cancer Screening benefit category. This means that you have been asked to pay the correct amount and the Plan has reimbursed you 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 provide additional reimbursement for the cancer screening services (G0101, Q0091) provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on December 29, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary. Our physician reviewer found that the documentation does not demonstrate that the cardiovascular risk assessment panel was necessary to diagnose, treat, or otherwise manage 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on December 21, 2020 and billed under code G0483.
You asked the Plan to pay for code G0483. You say that his claim should be paid. The Plan denied your request. The Plan says while code 80307 was paid, code G0483 cannot be paid due to an invalid place of service code on the claim. The Plan says that place of service reported on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.
Also, the laboratory results submitted indicate the specimen was collected on December 21, 2020 and received by the lab on December 29, 2020.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim cannot be fully paid due to an issue with the place of service code. Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on December 21, 2020 and billed under codes 80307 and G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the functional outcome assessments (G8942 x 2) and the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider on February 19, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the functional outcome assessments (G8942 x 2) and the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider on February 19, 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 the IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different 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. Our
physician reviewer found based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of 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