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

We decided that the Plan does not have to pay forthe surgical services (92250, 67220, 76512) provided on September 21, 2020.You asked the Plan to pay forthe surgical services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.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 services at issue in this appeal. The Plan did not pre-approve the service 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 forthe surgical services (92250, 67220, 76512) provided on September 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on April 10, 2020, to April 30, 2020.You asked the Planto waive the coinsurance for an injection. You say that you do not think this should be denied. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $10,676.05. The total amount you are being asked to pay is $2,135.21 ($10,676.05 x 20% = $2,135.21). These services were not denied. An injection falls within the Medicare Part B prescription drugs 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 paywhen you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on April 10, 2020, to April 30, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department services rendered on August 13, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that all hospital-based charges must be billed on TOB 13X.We looked at the file and Medicare rules. The file shows that the claim was not billed on the required TOB 13x. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency department servicesrendered on August 13, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foremergency room and ancillary charges for services provided on August 22 -August 26, 2020.You asked the Plan to pay forthe emergency room and ancillary charges. You say that you agree the enrollee did not meet the inpatient criteria for coverage but argue that the emergency room and ancillary services should be covered. You say that you cannot carve outthe emergency room and ancillary service charges from the inpatient claim.The Plan denied your request. The Plan says the emergency room and ancillary charges should be carved out and billed separately from the inpatient charges. The Plan says that corrected claims can be submitted with attention to Claims Adjustment.The Plan must follow Medicare rules. Medicare rules say that services that require an outpatient status and are provided only in an outpatient setting are not payable inpatient Part B services, including Clinic Visits, Emergency Department Visits, and Observation Services.
We looked at the file and Medicare rules. Since the Part A claim denied, payment cannot be made for the other services billed. Emergency department services requires an outpatient status, and an outpatient claim would need to be submitted for those services to be considered. Based on this information, we decided that Medicare rules for coverage of the emergency room and ancillary charges have not been met.Therefore,we decided that the Plan does not have to pay foremergency room and ancillary charges for services provided on August 22 -August 26, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the mobile x-ray services provided on September 12, 2020. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that the 
technical component of portable x-ray equipment transported to a skilled nursing facility is not separately 
reimbursable. 
 
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 looked at the file and the rules. The records show that the transportation component (R0070), and the set-
up component (Q0092) were billed correctly based on Medicare guidelines. Based on this information, we 
decided that Medicare rules for coverage have been met. Therefore, we decided that the Plan has to pay for the 
mobile x-ray services provided on September 12, 2020.  
 
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 pre-approvenon-emergency transportation by taxi (A0100).You asked the Plan to pre-approvetaxi. You say that the service is medically necessary.The Plan denied your request. The Plan says you have exhausted your Plan benefits for this service.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Specifically, you have already exhausted your 24 one-way routine trips for the 2020 calendar year.Therefore, we decided that the Plan does nothave to pre-approvenon-emergency transportation by taxi (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on September 14, 2020.You asked the Plan to reimburse you forthe dental services. You say that the services should be covered. You say that a licensed dentist performed the services. You also say that services that you received in February 2020 from the same provider were paid.The Plan denied your request. The Plan says the provider in this case has opted out ofMedicare. The Plan also says that payment cannot be made to providers who have opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray exam of the cervical spine (72040), x-ray exam of the lumbarspine (72100), and the office visit (99203) provided on October 15, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under the member's contractual policy or by Medicare.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe x-ray exam of the cervical spine (72040), x-ray exam of the lumbar spine (72100), and the office visit (99203) provided on October 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 
80159, and 80173 provided on February 17, 2020. 
 
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. 
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. 
 
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical 
record. Specifically, the documentation submitted did not support that these services were provided by blood 
specimen. Blood specimen collection is by venipuncture, however, the lab requisition states a urine specimen 
was collected; therefore, the billed services cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 
80157, 80177, 80201, 80162, 80159, and 80173 provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the enrollee is medically stable and that her needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's clinical complexities would 
be better served in an LTACH setting. The Plan denied your request. The Plan says the enrollee does not have 
complex enough medical conditions that require daily doctor visits. The Plan says that it is anticipated that the 
enrollee does not need an LTACH level of care for an extended time, and that her needs can be met at a lower 
level of care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve continued LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 continued LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an acute care hospital for respiratory failure following carotid surgery. You have a tracheotomy and has been weaned from the ventilator. The documentation does not support that you require ongoing LTACH 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 continued LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on July 24, 2020.
You asked the Plan to pay for the CxBladder testing. You say that you would like reconsideration because this testing is covered by Medicare. The Plan denied your request. The Plan says this is a non-covered service.
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder testing have not been met. Specifically, per Local Coverage Determination (LCD): Biomarkers for Oncology (L35396), CxBladder is non-covered. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from June 23, 2020 to September 8, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from June 23, 2020 to September 8, 2020.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99222) provided on September 5, 2020.
You asked the Plan to pay for the initial hospital are. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this is included in the global period of CPT code 61107 that was billed for the same date of service.
The Plan must follow Medicare rules. Medicare rules say that the initial evaluation is always included in the allowance for a minor surgical procedure. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the initial hospital are have not been met. Specifically, the record indicates that this service was the initial evaluation prior to a minor surgical procedure rendered by the same provider on the same date of service. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided on September 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to go to the LTACH for better therapy. You say that the enrollee is able to handle transport at this time. You say that the enrollee is feeding with a tube and that the LTACH is a better facility for what she needs. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 4, 2020.
You asked the Plan to pay for drug testing. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this was not billed correctly.
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 submitted medical records do not support that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for integrated biopsychosocial assessment services provided to 
the enrollee from July 4, 2019, to July 14, 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 original claim was not submitted within 365 days from the date of service. 
 
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 the services was not filed until October 22, 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 integrated biopsychosocial assessment services provided to the enrollee from July 
4, 2019, to July 14, 2019.