Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99204) individual psychotherapy (90833) provided on February 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you are no longer with the Plan because they do not pay for doctor approved and insurance approved medical/behavioral health services. You are enclosing copies of services the plan has not paid for. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 outpatient office visit (99204) individual psychotherapy (90833) provided on February 6, 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 pneumatic compressor from an out of network (OON) provider.
You asked the Plan to pre-approve the pneumatic compressor from an OON provider.. You say that you are the exclusive provider for the Lymphapress 12 chambered pneumatic compression device in the state of Arizona. You say that this exclusivity creates a network deficiency. You say that traditional pumps have no ability to focus treatment on fibrotic areas, they can only re-treat the entire limb which may be counterproductive to overall outcomes. The Plan denied your request. The Plan says there are in-network providers within a
reasonable distance from the enrollee's location that can provide the items needed. The Plan says that a network exception is not medically necessary.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 pneumatic compressor from an OON provider. Our reviewer says that the criteria for OON coverage have not been met. Our physician reviewer found the enrollee has chronic lymphedema. There is no evidence of an emergent or urgent condition. The documentation does not support that devices from this OON provider, rather than an in-network provider, are 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 the pneumatic compressor from an OON provider. have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor from an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95816, CPT 95957) provided to the enrollee on September 24, 2020.
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 records do 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. In this case, the CPT Code Manual definition of the denied codes is: CPT 95816: Electroencephalogram (EEG); including recording awake and drowsy CPT 95957: Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)
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 services at issue in this case were not supported by the medical records. Our coding reviewer found the documentation submitted does not include enough information to confirm all criteria for both CPT 95816 and CPT 95957 were performed. The EEG report does not specify time procedure was recorded, as well as recording of awake and drowsy, or documentation of epileptic spike analysis. Therefore, these procedures would not be covered. 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 neurology services (CPT 95816, CPT 95957) provided to the enrollee on September 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available in the service area.
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 care that cannot be provided by network providers. 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 a referral out-of-network for physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on February 10, 2021, by an
OON provider.
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not payable.
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 rest home visit provided on February 10, 2021,
by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient hospital clinic visits rendered from January 8, 2021 to February 5, 2021.You asked the Plan to waive the copayment forthese services. You say that you were told you would be fully covered.The Plan denied your request. The Plan says the copayments were applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for all other outpatient hospital services other than surgery. Review of the file shows that you had outpatient hospital clinic services on January 8, 2021 and February 5, 2021. You have been asked to pay a $35 copayment per date of service for these services, for a total of $70. These services fall within the all other outpatient hospital services other than surgery benefit category This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan is not denying coverage for these services. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe outpatient hospital clinic visits rendered from January 8, 2021 to February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic leg with a hydraulic knee and advanced foot and ankle.
You asked the Plan to pre-approve prosthesis with K3 knee and foot. You say that the enrollee, physician and prosthetist are all in agreement that the enrollee needs and upgrade/replacement from his current K2 above knee prosthesis due to increased functional ability to K3 level. The Plan denied your request. The Plan says the requested prosthesis exceeds the enrollee's need. Records do not support functional status has advanced to K3. The enrollee's current knee and foot are still under warranty. Medicare does not cover replacement for items still under warranty.
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 prosthesis with K3 knee and foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found review of records for current request show that member has 15-degree flexion contracture and requires use of cane. This is not consistent with K3 ambulation. The review has determined that the requested complete prosthesis with K3 knee and foot do not meet Medicare criteria as reasonable or 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 prosthesis with K3 knee and foot have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic leg with a hydraulic knee and advanced foot and ankle.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for arthroplasty provided on September 23, 2020.You asked the Plan to waive the deductible for arthroplasty. You say that you met the MOOP amount prior to receiving the services and disagree with how the claims were processed.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. Your contract with the Plan says that the MOOP amount for 2020 is $6,700. Your contract with the Plan also clearly says that there is a a $1,000 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthroplasty on September 23, 2020. The record shows that you have only paid $1,864.86 toward the $6,700 MOOP amount prior to receiving the services. Therefore, you are responsible to pay your share of the cost-sharing charges. The record shows that you had only paid $230.16 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $769.84. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time arthroplasty was received on September 23, 2020.Therefore, we decided that the Plan does not have to waive the deductible for arthroplasty provided on September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prostate genomic testing provided on November 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe prostate genomic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 networkprovider 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 theseitems/services.Therefore, we decided that the Plan does not have to pay forthe prostate genomic testing provided on November 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy services coded 99183 provided from July 8, 2020 to July 15, 2020.
You asked the Plan to pay for the physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy 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 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 99183 is physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session. We find that CPT code 99183 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session for the billed dates of service of July 8, 2020, July 13, 2020, July 14, 2020, and July 15, 2020; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy services coded 99183 provided from July 8, 2020 to July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network to a skilled nursing facility.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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 a referral out-of-network to a skilled nursing facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement provided by an out-of-network provider on January 21, 2021.You asked the Plan to pay for the wound debridement. You say that you were told that a referral could not be provided. You say that you were granted privileges to provide medically necessary services and the claim should be considered for payment.The Plan denied your request. The Plan says this provideris 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 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 wound debridement provided by an out-of-network provider on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing coded 95999 provided on November 2, 2020.
You asked the Plan to pay for the train of four 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 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, the CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that spinal surgery was completed. The records indicate that the enrollee underwent back surgery requiring neurophysiology monitoring. The services billed are considered a bundled procedure as the cost is included in the cost of the primary procedure. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing coded 95999 provided on November 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is motivated to return to his prior level of function. The Plan denied your request. The Plan says the enrollee does not need an intensive team for 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 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 physician reviewer found that the enrollee is at a minimal assist level for sitting up and standing up, and at a contact guard assist for walking using a rolling walker. 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.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex surgery.
You asked the Plan to pre-approve Vertiflex surgery. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertiflex surgery is considered experimental/investigational at this time.
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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex surgery.
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.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 atrial fibrillation with rapid ventricular response, congestive heart failure and pleural effusion. 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. 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.