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

We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on January 17, 2021.

You asked the Plan to pay for the outpatient clinic visit. You say that the patient was seen out of area. You say that the medical services were provided in good faith and payment should be made. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.

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 outpatient clinic visit provided by an out-of-network provider on January 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the laboratory services are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. One CPT code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdominal ultrasound (76700) performed on January 6, 2021.

You asked the Plan to waive the copayment for an abdominal ultrasound. You say that the provider is in-network.The Plan denied your request. The Plan says the correct copayment was 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 $100 copayment for diagnostic radiology. 

You have been asked to pay a $100 copayment for an abdominal ultrasound. An abdominal ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an abdominal ultrasound (76700) performed on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for supply allowance for therapeutic continuous glucose monitor (CGM)
includes all supplies and accessories, 1 month supply 1 unit of service (K0553) provided from January 1, 2021,
to February 1, 2021.
You asked the Plan to pay for the supply allowance for CGM. You say that documentation from the medical
record shows the enrollee is taking Humalog 100 unit/subcutaneous solution. The medical record supports the
addition of diagnosis code Z79.4 (long term/current use of insulin) to this claim. The Plan denied your request.
The Plan says that medical records from physician documents treatment with oral Metformin, no insulin.
Therefore, the continuous glucose monitor and/or supplies is not authorized.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 supply allowance for CGM. Our
reviewer says that the requested items/services are considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee is using the blood glucose data to adjust her doses at meals by cf 75.
She is using 4 shots insulin/d. She is being directed to check blood glucose 4 times a day at least and is likely
doing this although we are not given a blood glucose log, therefore, she meets criteria.
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 supply allowance for CGM have been met. Therefore, we decided that the
Plan has to pay for supply allowance for therapeutic continuous glucose monitor (CGM) includes all supplies
and accessories, 1 month supply 1 unit of service (K0553) provided from January 1, 2021, to February 1, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transportation (A0428), and
ground mileage (A0425) provided on October 2, 2020.

You asked the Plan to pay for non-emergency ambulance transportation, and ground mileage. You say that you
would like these services paid based on the medical records provided. The Plan denied your request. The Plan
says information provided at the time of the appeal does not support ambulance transportation. A physician's
office/clinic/outpatient clinic/outpatient surgery center is not a covered destination.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 non-emergency ambulance transportation,
and ground mileage. Our reviewer says that the documentation did not support that other means of transport
(such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this
patient. The documentation did not support that the patient needed the expertise, services and lifesaving and
life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The
documentation did not support that the ambulance transport was medically reasonable and necessary for the
patient. He was medically stable. There was no specific clinical rationale for ambulance transport.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of non-emergency ambulance transportation, and ground mileage have not been
met. Specifically, the ambulance transport was not medically reasonable and necessary. Therefore, we decided
that the Plan does not have to pay for non-emergency ambulance transportation (A0428), and ground mileage
(A0425) provided on October 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the sales tax applied on November 4, 2020.

You asked the Plan to issue reimbursement for the sales tax applied. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says sales tax charges are not eligible for reimbursement.

The Plan must follow Medicare rules. Medicare rules say that contractors do not make any additional payment for sales tax and do not make adjustments in fees to reflect local changes in tax rates. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sales tax have not been met. Specifically, the tax fees applied are not eligible for reimbursement. Therefore, we decided that the Plan does not have to issue reimbursement for the sales tax applied on November 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient physical therapy provided from September 16, 2020, through September 23, 2020.You asked the Plan to pay for the outpatient physical therapy. 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 outpatient physical therapy. 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 outpatient physical therapy provided from September 16, 2020, through September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on September 9, 2020.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 

We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. 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 drug testing coded G0483 provided on September 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on March 25, 2019, through March 28, 2019.
You asked the Plan to pay for home health services. You say that the claim was not filed untimely. The Plan denied your request. The Plan says the claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for home health services was not filed until October 2, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for home health services provided on March 25, 2019, through March 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walker provided on October 30, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the walker provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
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 walker provided on October 30, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy (CPT code 81551) provided to the enrollee on January 4, 2021.

You asked the Plan to pay for the laboratory testing. You say that the service should be covered based on Medicare rules. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Per Medicare rules, ConfirmMDx can be done on the prostate biopsy sample collected within last 24 months if the enrollee has persistent risk factors and is being considered for a second biopsy. ConfirmMDx is done to avoid a second biopsy. This enrollee already had a second biopsy and therefore does not qualify for ConfirmMDx. Therefore, we decided that the Plan does not have to pay for oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy (CPT code 81551) provided to the enrollee on January 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care billed with DRG 194, provided from
September 20, 2019, through September 30, 2019.
You asked the Plan to pay for inpatient hospital care billed with DRG 194. You say that the records support
DRG 194. The Plan denied your request. The Plan says the records do not support DRG 194 and should be
classified as DRG 195 instead.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
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 inpatient hospital care billed with DRG 194.
Our reviewer says that DRG 194 is not supported by the records. Our physician reviewer found based on
consensus criteria, for the diagnosis of acute renal failure, the medical record should reflect a clinically
significant rise of creatinine of 0.3 within 48 hours, or a rise of creatinine of 50% above baseline, or a reduction
in GFR of 25% or more below baseline, or a fall of urine output below 0.5 mL/kg/hr. for a minimum of 6 hours
(~ 200 ml in 6 hours). However, the records submitted do not support the diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care billed with DRG 194, provided from September 20, 2019, through September 30,
2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MAZE procedure, associated procedures, and inpatient admission.
You asked the Plan to pre-approve a MAZE procedure, associated procedures, and inpatient admission. 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. 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 a MAZE procedure, associated procedures, and inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The requested service cannot be recommended at this time.
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 MAZE procedure, associated procedures, and inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a MAZE procedure, associated procedures, and inpatient admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9945) received December 15, 2020.
You asked the Plan to pay for the occlusal guard. You say that you have a note from your doctor stating that the requested item was necessary. The Plan denied your request. The Plan says the requested item is not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard (D9945) received December 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF)admission.

You asked the Plan to pre-approve SNF admission. You say that the enrollee's provider says she needs rehabilitation services. The Plan denied your request. The Plan says there is no need for daily skilled therapy services and no daily skilled nursing needs.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the member has stabilized medically and
is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy
services on a daily basis. The member is medically stable and can receive further rehab services at a lower level
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the
intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The member
does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is
medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or
near her baseline and she can receive services at a lower level of care. Admission to a SNF for inpatient skilled
rehab services is 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 SNF admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF)admission.