Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0425, A0428) provided September 30, 2020.
You asked the Plan to pay for the non-emergency ambulance transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit.
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 the non-emergency ambulance transport. Our reviewer says that the service was not medically necessary. Our physician reviewer found that according to the provided documentation, the enrollee could have safely been transported via stretcher van. There was no contraindication for such on September 30, 2020. The documentation does not support that the enrollee required expertise or special equipment. The documentation does not sufficiently support that the ambulance services were medically necessary for this enrollee. 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 non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0425, A0428) provided September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82542, 84228, E0483) provided on September 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that you were not aware of the enrollee's insurance information and provided these services in good faith. The Plan denied your request. The Plan says these services were not authorized.

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 laboratory services (82542, 84228, E0483) provided on September 18, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cooling sleeve (CryoCuff) for the knee.
You asked the Plan to pre-approve a cooling sleeve. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a cooling sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a cooling sleeve (CryoCuff) for the knee.
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 IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 that the patient was admitted for traumatic injuries after a motor vehicle accident.
The patient was treated for respiratory failure, rib fractures, spinal fractures managed without surgery, delirium,
pneumonia and multiple fractures of right leg requiring surgery. Medical conditions are now stable. There are
no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The
patient does require physical and occupational therapy but there is no documented need for an intensive
rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion,
there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit for ophthalmology services (92004, 78519) provided on January 12, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were unaware that the provider had not received prior authorization for the visit. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization. The Plan also says there are in-network providers available for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit for ophthalmology services (92004, 78519) provided on January 12, 2021, by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99283) provided December 19,
2020.
You asked the Plan to pay for the emergency room services. You say that the services were medically
necessary. The Plan denied your request. The Plan says this CPT code shares a column I/column II relationship
with another service billed and is not separately 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. In this case, we have confirmed that code 99283
has a Column I / Column II relationship with code 99284 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 emergency room services (99283) provided
December 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray provided by an out-of-network provider on January 15, 2021.

You asked the Plan to pay for the hip x-ray. You say that you do not have the opportunity to pre-authorize radiology studies or verify if the providers are in-network prior to the services being rendered. You say that you are requesting retro authorization and the claim to be paid. The Plan denied your request. The Plan says the non-contracted provider performed the services without obtaining 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 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 hip x-ray provided by an out-of-network provider on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided to the enrollee on October 14, 2020.

You asked the Plan to pay for the CGM. You say that the CGM should be covered. The Plan denied your request. The Plan says the Medicare coverage criteria were not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic continuous glucose monitor (CGM) provided to the enrollee on October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve second set of diagnostic facet joint injections.
You asked the Plan to pre-approve second set of diagnostic facet joint injections. You say that this service is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a second diagnostic facet joint procedure is medically reasonable and necessary when there is a consistent positive response of at least 80% relief of primary (index) pain. 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 second set of diagnostic facet joint injections. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found there is inadequate documentation of the effectiveness of the first set of diagnostic blocks. Therefore, at this time, the request is deemed not medically reasonable or necessary without this
information. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of second set of diagnostic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve second set of diagnostic facet joint injections.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate 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 enrollee requires additional short-term acute care services for additional oxygen weaning which can safely be administered at the current facility. enrollee does not require services at the LTACH that are not already available and being received at the current facility.
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 lab services (G0483) provided September 22, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 code G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests, supplies, EKG and pharmacy services provided September 24, 2020 to September 30, 2020.
You asked the Plan to pay for the inpatient services. 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 these services is included in the facility payment amount.
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 enrollee was provided these service s while inpatient. Payment for these services would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the inpatient services. Non-contract providers must accept as payment in full payment amounts applicable in Original Medicare. Thus, this provision of law imposes a cap on payment to non-contract providers of provider payment amounts plus beneficiary cost-sharing amounts applicable in Original Medicare and ensures that non-contract providers not balance bill MA plan enrollees for other than MA plan cost-sharing amounts. You can find this information in CMS - Medicare Managed Care Manual Chapter 6 - Relationships With Providers, Section 100, Consistent with 1852(a)(2) and 1852(k)(1) of the Social Security Act. Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for lab tests, supplies, EKG and pharmacy services provided September 24, 2020 to September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nail debridement procedure provided on
December 22, 2020.

You asked the Plan to waive the copayment for podiatry visit. You say that you cannot cut your toenails, and
you would appreciate it if the Plan paid for this service. The Plan denied your request. The Plan says the
copayment amount you are being charged is correct.

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 $35
copayment for podiatry visit.

You have been asked to pay the allowed amount of $31.84, which is less than the $35 copayment for podiatry
visit. Podiatry visit falls within the Podiatry Services benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for a nail debridement procedure provided on December 22, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that this member could receive additional therapy at Subacute Rehab Facility, or home with supervision and home health care services or long-term care placement.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for knee replacement surgery. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 6, 2021, through May 7, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient stay was medically necessary. The Plan denied your request. The Plan says that you do not meet the Medicare guidelines for an inpatient admission.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that you have a history of hypercholesterolemia and you presented to the emergency department (ED) on May 6, 2021 for the evaluation of back pain and a cough. The record sent by your provider indicates that while in the emergency room, you had a normal Troponin levels, normal vital signs including oxygen levels, and a normal chest x&#8208;ray. The chest computed tomography scan did not show any blood clots but showed a lung mass. You were admitted and you underwent a bronchoscopy with biopsy, and you were seen by an oncologist who arranged for outpatient follow&#8208;up. You were discharged home on May 7, 2021. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED and/or observation care) would span two midnights.

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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 6, 2021, through
May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brilinta 90 mg tablet.
You asked the Plan to pre-approve Brilinta. You say that it is medically necessary the enrollee remain on this medication. The Plan denied your request. The Plan says this drug is not among those covered by the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Brilinta 90 mg tablet.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided during the outpatient
observation stay from February 7, 2021, through February 9, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you received a bill and want it to be
covered. The Plan denied your request. The Plan says self-administered drugs are not covered in an outpatient
hospital setting.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided during the outpatient observation stay from February 7, 2021, through February 9, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.