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

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on September 15, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.
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 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 domiciliary or rest home visit provided on September 15, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on May 2, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were admitted to the hospital so should not be responsible for the charges. 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 $75 copayment for ambulance services. The medical records show that you received ambulance services on May 2, 2020, and were transferred home, not to a hospital facility. Therefore, you are responsible to pay the $75 copayment. You have been asked to pay a $75 copayment for ambulance services. Ambulance services fall 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 copayment for ambulance services provided on May 2, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on August 5, 2020.

You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request. The Plan says CPT code 99284 is more appropriate.

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 99285 is "emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function."

We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the records do not support CPT 99285. The documentation supports a detailed history and exam, and medical decision making of moderate complexity with laboratory testing, and IV therapy with medication. The documentation states radiology testing, however, no results were noted in documentation to support services. CPT 99285 would be incorrect code to report, as there is no documentation to support medical decision making of high complexity.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (CPT 99285) provided to the enrollee on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on November 18, 2020.

You asked the Plan to waive the copayment for vision services. You say that this was a normal eye exam. You say that you should not have a copayment for this. The Plan denied your request. The Plan says the correct copayment 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 a $50 copayment for vision care/in-network/treat conditions of the eye. 

You have been asked to pay a $50 copayment for vision services. The correct copayment has been applied to the services that were provided. Vision services fall within the vision care/in-network/treat conditions of the eye 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 vision services provided by a participating provider on November 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the brief emotional/behavioral assessment and domiciliary or rest home visit provided on November 18, 2020 by an OON provider.
You asked the Plan to pay for the brief emotional/behavioral assessment and domiciliary or rest home visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not obtained.
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 the brief emotional/behavioral assessment and domiciliary or rest home visit provided on November 18, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided from June 21, 2020, through July 3, 2020.
You asked the Plan to pay for the ambulance services. You say that your requesting for enrollee responsibility for this service. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 21, 2020 to July 3, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided from June 21, 2020, through July 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available 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 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 physician services provided on October 17, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the provided neuromuscular electrical stimulation (E0745) device and supplies (A4245 and A4595) provided on June 5, 2020.
You asked the Plan to pay for the provided neuromuscular electrical stimulation device and supplies. You say that the provided neuromuscular electrical stimulation (E0745) device and supplies (A4595) were medically necessary. The Plan denied your request. The Plan says the services are not covered.
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 provided neuromuscular electrical stimulation device and supplies. Our reviewer says that the provided neuromuscular electrical stimulation (E0745) device and supplies (A4245 and A4595) were not medically necessary. Our physician reviewer found the enrollee was being treated for low back pain, sprain of ligaments, pain in left and right knee and ankle, muscle wasting. She cited back pain, knee pain, and ankle pain. Exam reveals 5-year history of back and knee pain and 2-year history of ankle pain. She is experiencing limitations and indicating pain is increased during lateral flexion, extension, and flexion. However, this device has not been proven in large volume-long term medical literature to be an effective treatment in this clinical scenario. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the requested neuromuscular electrical stimulation (E0745) device and supplies (A4595) was not medically reasonable or necessary. The rules also say providers must report services correctly. In this case, CPT code A4245 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes. 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 provided neuromuscular electrical stimulation device and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the provided neuromuscular electrical stimulation (E0745) device and supplies (A4245 and A4595) provided on June 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy (45380) provided December 2, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was a routine colonoscopy, and the copayment should be waived. The Plan denied your request. The Plan says the service billed was not a routine preventative colonoscopy. The correct copayment was applied for the service billed by the provider.
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 ambulatory surgery. You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the ambulatory 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 (45380) provided December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214} provided on January 12, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that this doctor has been your primary care provider for years. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visit (99214} provided on January 12, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for thesupply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided November 2, 2020.You asked the Plan to pay for thesupply allowance for therapeutic CGM. You say that you have attached documents for review in regards to the denial.The Plan denied your request. ThePlan says the enrollee does not meet the criteria as the records provided documents blood sugar check and insulin dosage 2 times daily.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of supply allowance for therapeutic CGM have not been met.Therefore, we decided that the Plan does not have to pay for thesupply allowance for therapeutic continuous glucose monitor (CGM) (K0553) provided November 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for a patient lift provided from October 26, 2020, through October 28, 2020.
You asked the Plan to pay for the patient lift. The Plan denied your request. The Plan says the Plan does not cover services for members in a hospice election period.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for a patient lift provided from October 26, 2020, through October 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on January 16, 2021.You asked the Plan to waive the copayment foremergency care. You say that you did not receive some of the services the provider is billing for.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 $90 copayment for emergency care. The medical records show that you receivedemergency care on January 16, 2021. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 foremergency care provided on January 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of home health/hospice aide in home health or hospice settings, each 15 minutes, and direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.
You asked the Plan to pre-approve the home health services. You say that you are not able to sort your medications on your own. You say that the nurse was very helpful for you to have all of your medical needs. The Plan denied your request. The Plan says the provided documentation does not show that you have a medical need that only a skilled nurse can do.
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 home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found the provided documentation does not show that you require additional skilled nursing services, or home health aide services to provide treatment that is medically necessary.
The reviewer found that you do not require skilled nursing to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of home health/hospice aide in home health or hospice settings, each 15 minutes, and direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 19, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you feel that you should not owe a copayment because the provider failed to send in the required documents for a denied pre-approval. 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 $30 copayment for specialist services. The medical records show that you had a specialist visit on January 19, 2021. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on January 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 9, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and your lab is the sole provider for this test. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not meet the Medicare criteria for coverage of this test.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This laboratory testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on November 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (T1000) provided February 6, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support the 78 units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 78 units of CPT code T1000 are not supported in the medical record. The medical record only supports 76 units of CPT code T1000. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services (T1000) provided February 6, 2020.