Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine skilled nursing home care visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that the enrollee has already had multiple home skilled nursing visits, and the enrollee's current condition does not require additional visits.
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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the request for nine skilled nursing home care visits is not medically necessary. The documentation does not reveal the need for the professional skills of a nurse to effectively provide treatment, care, and/or services which are medically necessary for you. There is no complex wound care, new tracheostomy tube or other skilled nursing need. There is no evidence that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for you. You have had extensive therapy and patient and caregiver instructed on a maintenance program. For these reasons the requested home health services are 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve nine skilled nursing home care visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on August 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the out of network SNF services. You say that the medical records support the medical necessity of the services in dispute for treatment of the enrollee's chronic conditions. The Plan denied your request. The Plan says prior authorization was not obtained, as is required under 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 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 skilled nursing facility (SNF) services provided on August 28, 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 rendered on April 12, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on April 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing provided to the enrollee on March 27, 2019.
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the place where the sample was taken is reported as the Place of Service (POS).
We find that the CPT codes have not been billed with the correct place of service code. The records provided do not indicate that the sample at issue was taken at an independent lab. 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 presumptive and definitive drug testing provided to the enrollee on March 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital services provided on October 9, 2019 to October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for initial hospital services. 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 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 initial hospital services provided on October 9, 2019 to October 10, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ultrasound (76770) provided on June 17, 2019. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says no plan contact was made prior to the services rendered to review benefits/eligibility and no authorization request was submitted for use of out-of-network providers.
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 the medical services provided on June 17, 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 to the enrollee on April 25, 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 to the enrollee on April 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 26, 2019 by an out of network (OON) provider.
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 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 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 the medical services provided on August 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat series of Euflexxa injections.You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee received a series of Euflexxa six months ago and it was helpful which is why she has returned for a repeat series.The Plan denied your request. The Plan says the record did not specifically state the level of pain relief from the last injection or how long it lasted so therefore, she cannot receive another treatment.The Plan follows Medicare rules. Medicare rules say that repeat viscosupplementation injections may be covered when there is documentation of significant pain relief and functional benefit. 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 Euflexxa injections. Our reviewer says that the criteria to support medical necessity are not met. Our physician reviewer found although the progress note documents that there was improvement, the documentation does not clearly describe that there was adequate pain relief or functional benefit.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 Euflexxa injections have not been met.Therefore, we decided that the Plan does not have to pre-approve a repeat series of Euflexxa injections
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 28, 2019.
You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your
request. The Plan says this is included in the global surgery package.
The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for procedures
with global surgical periods includes payment for postoperative visits. Services submitted with the "-24"
modifier must be sufficiently documented to establish that the visit was unrelated to the surgery.
We looked at the file and Medicare rules. The surgical procedure (14301) performed on August 8, 2019, has a
global surgical period of 90 days. The office visit in question was provided less than 90 days after the
procedure by the same provider that performed the procedure. Although it was billed with Modifier 24, the
record does not indicate it was unrelated to the surgical procedure. The record and diagnosis codes indicate it
was a post-operative visit. Based on this information, we decided that Medicare rules for coverage of an office
visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99213)
provided on August 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 19, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that there should not be a copayment because the first hospital did not have the needed equipment. The Plan denied your request. The Plan says that cost shares are a contractual obligation.
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 $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on September 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly MINIMUM/MODERATE assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin assay panel provided to the enrollee on August 29, 2019.You asked the Plan to pay for the vitamin assay panel. 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 test at issue in this appeal, the vitamin assay panel, 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 for the vitamin assay panel provided to the enrollee on August 29, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe craniotomy for evacuation of a hematoma provided on December 13, 2018 by an out of network (OON) provider.You asked the Plan to pay forthe surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says that the services could be provided in network.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 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 forthe craniotomy for evacuation of a hematoma provided on December 13, 2018by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial nursing facility care provided on July 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that although the provider in this case is out of network, the facility is in network.The Plan denied your request. The Plan says there was not a paid facility claim for the date of service July 24, 2019. The Plan also says there is not a referral from a contracted provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for carefrom 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 documentation provided does not show that the enrolleewas referred by a network provider. 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 forthe initial nursing facility care provided on July 24, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) (93307).
You asked the Plan to pre-approve the TTE. You say that the TTE is medically necessary. The Plan denied your request. The Plan says the rules for coverage have not been met.
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 TTE. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has known coronary disease but no documented valve disease, no cardiac symptoms, a normal cardiac physical exam, no ischemic ECG changes and recent normal ventricular function and no ischemic on stress testing. 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 TTE have not been met. Therefore, we decided that the Plan does not have to pre-approve Transthoracic Echocardiography (TTE) (93307).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurotherapy program for enrollee.You asked the Plan to pre-approve these services. You say that the enrollee has chronic pain syndrome.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the services are neurotherapy to be performed by a chiropractor.Therefore, we decided that the Plan does not have to pre-approve a neurotherapy program for enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora duplex scan of extremity veins (93971) provided on May 9, 2019.You askedthe Plan to pay fora duplex scan of extremity veins. You say that this should be paid.The Plan denied your request. The Plan says the referring provider has been excluded/sanctioned by the Office of the Inspector General.The Plan must follow Medicare rules. Medicare rules say that the Office of the Inspector General (OIG) maintains a sanction list that identifies those individuals found guilty of fraudulent billing, misrepresentation of credentials, etc. No Federal health care program payment may be made for any items or services furnished at the medical direction or on the prescription of an excluded person.We looked at the file and Medicare rules. The referring provider for the service at issue is listed by the Office of the Inspect General as an excluded provider. Payment cannot be made for services ordered by an excluded provider. Based on this information, we decided that Medicare rules for coverage of a duplex scan of extremity veins have not been met.Therefore, we decided thatthe Plan does not have to pay fora duplex scan of extremity veins (93971) provided on May 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on May 11, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the records do not indicate a clear intent to order the lab.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 documentation of the ordering physician's intent that the tests 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 forthedrug testing services provided to the enrollee on May 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin eye injections to be provided by requested provider.You asked the Plan to pre-approve Avastin eye injections. You say that you must receive Avastin eye injections every two weeks while you are in Florida. Your doctor informed you that the injections must be continued every six weeks. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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 services. Therefore, we decided that the Plan does not have to pre-approve Avastin eye injections to be provided by requested provider.