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

We decided that the Plan does not have to pay for office visit services provided by a Medicare non-certified provider on November 18, 2019. 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 the provider is not certified with Medicare and has opted out.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. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay for office visit services provided by a Medicare non-certified provider on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 5, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this member had multiple exams on the same date of service. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.
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 71045 is not supported in the record. Specifically, the record indicates that one x-ray was rendered by the provider. This service was paid for by the Plan and there is not sufficient documentation to support that a second chest x-ray was provided by this physician. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on February 5, 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that you require this on an 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 definitive drug testing provided on November 25, 2019.
You asked the Plan to pay for the drug testing. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records.
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 G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. There were insufficient records that show the tests were needed to identify specific substances that were inadequately detected by a presumptive drug test. There is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on January 16, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that you were told this provider accepted your
insurance. The Plan denied your request. The Plan says this service was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 an office visit (99204) provided on January 16,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on December 11,
2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the record. Specifically, the record does not include the
amount of time spent rendering critical care services on the billed date of service. Based on this information,
we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we
decided that the Plan does not have to pay for critical care services (99291) provided on December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on March 31, 2020by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that there is a medical necessity pre-established with the enrollee and the facility.The Plan denied your request. The Plan says prior authorization wasnot obtained as outlined in the plan benefits.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 documentation shows that the enrollee received complex chronic care management services. The 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. 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 forthe medical services provided on March 31, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on March 1, 2020.You asked the Plan to pay forthe provided drugs. The Plan denied your request. The Plan says the drugs are not covered services under your plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The file shows that you received medications during an emergency room visit. Drugs you would normally take on your own that you receive during outpatient services are considered self-administered drugs. The self-administered drugs you received are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay forthe self-administered drugs provided on March 1, 2020.Benefits for the provided drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided on March 9, 2020.
You asked the Plan to waive the copayment for diagnostic mammogram. You say that this was your annual mammogram and should be paid at 100% as preventive care. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $75 copayment for diagnostic mammogram. The records show that this mammogram was ordered as a diagnostic test, therefore the screening mammography benefit does not apply to this claim. You have been asked to pay $75 copayment for diagnostic mammogram. Diagnostic mammogram 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 a diagnostic mammogram provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) and arm splint
application (29105) provided on October 24, 2019.
You asked the Plan to pay for the adjacent tissue transfer and arm splint application. You say that you would
like reconsideration based on the records submitted. The Plan denied your request. The Plan says the
documentation submitted does not support the services billed.
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 14301 is adjacent tissue transfer or rearrangement, any
area; defect 30.1 sq cm to 60.0 sq cm.
The CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each
additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure).
The CPT Code Manual definition of code 29105 is application of long arm splint (shoulder to hand).
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 adjacent tissue transfer and arm splint application. Our
reviewer says that CPT codes 14301 and 14302 do not meet criteria for billing or reimbursement consideration.
The medical records do not include documentation for an adjacent tissue transfer or rearrangement, any area;
defect 30.1 sq cm to 60.0 sq cm or an adjacent tissue transfer or rearrangement, any area; each additional 30.0
sq cm, or part thereof. Our reviewer found CPT code 29105 does not meet criteria for billing or reimbursement
consideration. The medical records not include documentation in the operative report that describes the
Application of long arm splint (shoulder to hand) being done.
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 adjacent tissue transfer and arm splint application have not been met.
Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) and
arm splint application (29105) provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0651, E0667).
You asked the Plan to preapprove a pneumatic compression device. You say that the PCD is necessary. The Plan denied your request. The Plan says there was no record of failed conservative therapy treatment.
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of lymphedema after a four-week trial of conservative therapy demonstrating failed response to treatment with compression stockings, elevation, and exercise. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. There is no evidence that the patient has consistently employed these conservative measures for any length of time, and no documentation of measurements taken at any time. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0651, E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on February 18, 2020.You asked the Plan to pay forthe services. The Plan deniedyour request. The Plan says this is not a covered service.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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent disease testing provided on February 4, 2020.You asked the Plan to pay for infectious agent disease testing. You say that you have billed for medically necessary testing as ordered by the enrollee's provider.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not a Medicare benefit for the diagnoses listed.The Plan must follow Medicare rules. Medicare rules say that lab code 87798 is only covered when billed with at least 1 of a set of certain diagnosis codes. Diagnosis codes N39.0, R10.2,and N39.41 are not among those for this this test code may be covered.We looked at the file and Medicare rules. The documentation does not show that this testing was ordered or billed with a covered diagnosis code. Based on this information, we decided that Medicare rules for coverage of infectious agent disease testing have not been met.Therefore, we decided that the Plan does not have to pay for infectious agent disease testing provided on February 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from July 14, 2019 to November 2, 2019.
You asked the Plan to pay for the inpatient psychiatric hospital services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the request is not medically necessary because the records received show the enrollee's condition will not improve and the enrollee will need to be placed in a living situation where she can be taken care of.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient psychiatric hospital services were not medically reasonable and necessary for the enrollee in this case. This enrollee did not appear to require inpatient mental health treatment as she was not a danger to herself or others and was cooperative with care without any aggressive behaviors. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for the inpatient psychiatric hospital services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric hospital services provided to the enrollee from July 14, 2019 to November 2, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forphysical therapy provided on January 22, 2020.You asked the Plan to waive the copayment forphysical therapy. You say that you were informed if you needed a follow-up visit, you would not be charged.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 $40 copayment for each physical therapy, occupational therapy, and speech language therapy visit.You have been asked to pay a $40 copayment for the physical therapyvisit. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up visit.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 agreedto pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forphysical therapy provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided on October 18, 2019.
You asked the Plan to pay for hospital care. You say that this was a medically necessary service. The Plan denied your request. The Plan says this is must be billed to the enrollee's primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to bill the enrollee's primary insurance. As the secondary insurer, the Plan cannot be held responsible for hospital care until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for hospital care (99233) provided on October 18, 2019.