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

We decided that the Plan does not have to pay for a home visit providedon December 4, 2019.You asked the Plan to pay for the home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 a home visit providedon December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation (RFA) of L4-L5.You asked the Plan to pre-approvethe RFA of L4-L5. You say that the enrollee has radiating pain, a disc bulge, and narrow faucet arthrosis.The Plan denied your request. The Plan says the clinical information provided does not show that the criteria for coverage have 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 RFA of L4-L5. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. The enrollee had an L4-L5 laminectomy and fusion. She underwent diagnostic medial branch blocks at L3-L4 and L5-S1 and achieved 90% pain relief for 24 hours. Our physician reviewer says that performing medial branch blocks at the level of a prior surgery is not evidence based.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 RFA of L4-L5 have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation (RFA) of L4-L5.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from December 23, 2019 to December 31, 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 RAP is required to process final, per Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the denied home health services are not supported in the medical record. Specifically, the RAP claim was not billed in this case. 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 home health services provided to the enrollee from December 23, 2019 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 10, 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
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The
Plan says that the referring provider is also out-of-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 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 physician services provided on March 10, 2020 by
an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe DME provided on March 14, 2020.You asked the Plan to waive the coinsurance forthe DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME provided on March 14, 2020. You were asked to pay 20% coinsurance for any DME received. 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 coinsurance forthe DME provided on March 14, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Guardant360 testing provided on October 24, 2019.
You asked the Plan to pay for genetic testing. You say that you are appealing this denial. The Plan denied your
request. The Plan says that the denial of payment for this testing is correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering provider was in-network or outof-
network with the Plan. The documentation submitted does not include prior notice that this testing would not
be covered. Without this information, we cannot determine whether the lab order made constituted plandirected
care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or
justified by Medicare rules. Therefore, we decided that the Plan has to pay for Guardant360 testing provided on
October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 16, 2020.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on March 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided from June 5, 2019 to July 17, 2019.You asked the Plan to pay for HBO therapy. You say that this should be covered under your naturopathic benefit.The Plan denied your request. The Plan says this is not covered for your conditions. The Plan must follow Medicare rules. Medicare rules say that coverage for HBO therapy is limited to the above listed conditions.We looked at the file and Medicare rules. The record does not show that you have a covered condition. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met.Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided from June 5, 2019 to July 17, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 2, 2019 to December 30, 2019.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not submitted with the correct type of bill per Medicare payment guidelines.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. The rules say the Type of Bill is a required data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 2, 2019 to December 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee on December 3, 2019.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that there was no daily skilled nurse or therapist need.
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 pay for the SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided to the enrollee on December 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is not enough information to show that this device is safe and effective.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of this device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G orthotic device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, 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. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).You asked the Plan to pre-approve a PMD. You say that a PMD would support your continued health and safety in the community.The Plan denied your request. The Plan says that you are expected to recover from your episode of gout and be able to manage your basic daily tasks.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a PMD. Our reviewer says that a PMD is not medically reasonable and necessary in this case. You have a personal mobility deficit but the documentation does not indicate that it impairs participation in MRADLs. The mobility deficit is helped by the use of a walker. You are unsafe to use a PMD per a 4/2/20office visit noting use of sedating medications and prior documentation of poor impulse control. Our physician reviewer found that your condition does not meet Medicare criteria for a PMD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a power mobility device (PMD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or
heat exchanger (99190) provided on January 29, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this
service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on January 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on March 18, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you had to seek ER services due to
the inability to have office visits. You say that it shouldn't be your fault that you were unable to see your
doctors. 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 $90
copayment per visit for Medicare-covered emergency care.
You have been asked to pay $71.39, which is less than the standard $90 copayment for the ER visit. The ER
visit falls within the "Emergency care" benefit category. The records show that you were seen in the ER. 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 ER visit provided on March 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 71045 provided on February 10, 2020.You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare payment rules say procedure codes that are incorrectly reported with other procedure codes as a result of the misuse of the column two code with the column one code are not payable as there are limited circumstances when the column two code may be reported on the same date of service as the column one code. In this case, CPT code 71045 is a column two code and cannot be billed with column one code, 36556.Therefore, we decided that the Plan does not have to pay for CPT code 71045 provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 13, 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 approved for payment. The Plan denied your request. The Plan says 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 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 physician services provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for dermatology services. You say that you did not need prior authorization for previous services.The Plan denied your request. The Plan says prior authorization was not 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 dermatology services provided on September 30,2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance formonthly rental of an oxygen concentrator and portable oxygen provided from November18, 2019 through March 18, 2020.You asked the Plan to waive the coinsurance forthe DME. You say that you should not be responsible for the cost-share because you did not use the equipment.The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 and 2020 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Plan received a copy of the Delivery Ticket from the provider, signed by you anddated November 18, 2019, which confirms that you received the oxygen concentrator and portable oxygen and they are rented monthly. The Plan also received a copy of the pickup ticket from the provider, signed by you and dated April 1, 2020, which shows youreturned the portable oxygen on April 1, 2020. The Plan follows Medicare criteria, and Medicare classifies HCPCS codes (Healthcare Common Procedure Coding System) and how they are paid. According to Medicare HCPCS Code E1390(oxygen concentrator) and E0431(portable oxygen) are considered capped rental items, meaning that they are paid per month for the item. This means that if you have the item for any amount of time within that month, then the provider has the right to bill for entire month. Therefore, you are asked to pay 20% coinsurance for the DME. 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 coinsurance formonthly rental of an oxygen concentrator and portable oxygen provided from November 18, 2019 through March 18, 2020.