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

We decided that the Plan does not have to pre-approve oncology services to be provided by out of network provider.
You asked the Plan to pre-approve out-of-network oncology services. You say that the requested provider is closer to the enrollee's home. The Plan denied your request. The Plan says there is an in-network provider located 23 minutes from the enrollee's home.
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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E2100), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on June 20, 2019 to September 8, 2019.
You asked the Plan to pay for a blood glucose monitor, test strips, lancets, calibrator solution, and a lancing device. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for a blood glucose monitor (E2100), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on June 20, 2019 to September 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 2 support surface mattress (E0277).  You asked the Plan to pre-approve the mattress. You say that the ongoing use of the group 2 pressure relief mattress is medically necessary for preventive purposes. The Plan denied your request. The Plan says Medicare does not cover the cost of an air mattress/group II support surface for preventative purposes.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve the group 2 support surface mattress (E0277).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient behavioral health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of October 29, 2019 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any aggressive or sexually inappropriate behaviors. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient behavioral health services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
You asked the Plan to pre-approve Long-Term Acute Care Hospital (LTACH) service. You say that a Skilled Nursing Facility (SNF) is unable to provide the level of care that the enrollee currently requires. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network LTACH.
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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 17, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88342, 88341, 88305) provided on July
25, 2019 by out of network provider.
You asked the Plan to pay for lab services. You say that you are appealing the claim payment denial for
services rendered to the Plan's member on date of service July 25, 2019. You say the patient's health care
provider took the specimens to your office for analysis. You further say that the provider was authorized. The
Plan denied your request. The Plan says the doctor is a non-participating provider. The Plan says that the
referring provider is also a non-participating provider. The Plan says that it did not authorize any
services for either doctor who are non-participating providers. The Plan also says that services
are not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the
members residence that could have rendered the 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 laboratory services (88342, 88341, 88305)
provided on July 25, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient level of care.
You asked the Plan to pre-approve acute inpatient level of care. You say that the requested acute inpatient level of care is medically necessary. The Plan denied your request. The Plan says the requested acute inpatient level of care is not medically necessary.
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 acute inpatient level of care. Our reviewer says that the requested acute inpatient level of care is not medically necessary. Our physician reviewer found the enrollee presented to the emergency department on 1/19/20 after a well check by police. She was brought to the emergency department for social reasons. She was unable to provide any significant history secondary to her mental status. On evaluation her vital signs were stable and her lab studies revealed a possible urinary tract infection (UTI). CT of the brain did not demonstrate any acute process. She was started on IV Ceftriaxone. She was admitted to the medical floor. Her condition stabilized and improved and she was discharged home on 1/22/19. The review has determined that the enrollee was stable and appropriate for observation level of care services after the emergency room evaluation on 1/19/20. The enrollee did not require or receive any inpatient diagnostic studies or therapeutic interventions. The review has determined that the requested acute inpatient level of care services were not medically reasonable and necessary for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transport chair (E1038).
You asked the Plan to pre-approve the transport chair. You say that you are 97 years old and your daughter takes you around but she is 72 years old with a bad back and does not have enough strength to carry the wheelchair so you need a portable one. The Plan denied your request. The Plan says the transport chair does not serve a different purpose than the wheelchair that you already have.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have standard wheelchair. The standard wheelchair serves the same purpose as the transport chair. Therefore, we decided that the Plan does not have to pre-approve transport chair (E1038).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95999) provided on
September 4, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service
cannot be verified.
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 95999 is "Unlisted neurological or neuromuscular
diagnostic procedure".
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 use
of CPT code 95999 is not supported by the records provided. Our coding reviewer found that the claim
indicates that this CPT code was reported for train of four testing. According to CPT rules, train of four is
included in other neuromonitoring procedures and is not separately reportable. There is no evidence that a
procedure was performed that is not included in an existing neurological or neuromuscular diagnostic CPT
code.
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 the services (CPT 95999) provided on September 4, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 10, 2019.
You asked the Plan to waive the copayment for an office visit. You say that this was an annual wellness visit and you disagree with 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 $10 copayment for each primary care provider visit. The medical records show that you received services beyond an annual wellness visit on September 10, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office 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 an office visit provided on September 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lymphedema therapy services.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no diagnosis of lymphedema, and the etiology of the enrollee's edema is not clear.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is described as having mild edema, with easily palpable pedal pulses despite severe obesity. There is sparing of foot which is less likely to be lymphedema. There is no diagnosis of lympehedma documented in the medical record. The documentation does not support that there has been a change in patient condition necessitating specialty lymphedema care. The enrollee has been non-compliant with compression stockings. This cannot be considered failure of other therapies. As the documentation does not demonstrate significant severity, the diagnosis of lymphedema, nor the failure of recommended therapies, the plan determination cannot be overturned on the basis of medical necessity. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve lymphedema therapy services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services from June 4, 2019 through June 26, 2019, for the enrollee.
You asked the Plan to pay for the continuation of SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for continuation of SNF care. The Plan says the enrollee entered the hospice program on June 19, 2019. Therefore is covered by traditional Medicare beginning June 19, 2019 because the Plan's benefits terminated on the day the enrollee entered the hospice program. 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. 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.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny SNF services beginning on June 19, 2019 due to the enrollee entering the hospice program. The Plan failed to provide valid proof that the enrollee's hospice election was in effect at the time of the requested 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was treated for agitation. He was alert with confusion. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a moderate assist for functional mobility including gait to 40 feet with a rolling walker. He also used a mechanical lift for transfers. The enrollee required varying assist with activities of daily living. He tolerated a mechanical soft diet and nectar thickened liquids. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for 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 continuation of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continued skilled nursing facility (SNF) services from June 4, 2019 through June 26, 2019, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on August 6, 2019 to October 25, 2019.
You asked the Plan to pay for a blood glucose monitor, test strips, lancets, calibrator solution, and a lancing device. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for a blood glucose monitor (E0607), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on August 6, 2019 to October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory blood pressure monitor (A4670) provided on April 19, 2019.
You asked the Plan to pay for the ambulatory blood pressure monitor. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says payment for this would be included in the payment for the ambulance service.
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, we have confirmed that code the ambulatory blood pressure monitor has a bundled relationship with code A0426 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the ambulatory blood pressure monitor (A4670) provided on April 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
You asked the Plan to pre-approve colonoscopy. You say that this facility is in the process of becoming in-network with the Plan. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network 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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee will not require skilled services on a daily basis or skilled rehabilitation services.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.