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

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that The enrollee was in a nursing home for treatment. Please review this claim and process it for payment. 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 subsequent nursing facility care (99309) provided on December 28, 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 subsequent nursing facility care (99309) provided on
August 31, 2020, by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that your provider provided
medically necessary services in good faith. In consideration for the services rendered, your doctor is seeking
reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services
from an in-network provider. The plan says if an enrollee requires medical care that Medicare requires the plan
to cover and there are no in-network providers who can provide the care then the enrollee can receive the care
from an out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 subsequent nursing facility care (99309)
provided on August 31, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on October 4, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on October 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging,
tomographic (SPECT) (78452) provided May 22, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you are appealing the
charges and requesting review. The Plan denied your request. The Plan says this claim was processed with the
correct copayment applied per the Evidence of Coverage.
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 $100
copayment for each Medicare covered radiological diagnostic service not including x-rays performed in a
physician's office or at a freestanding facility.
You have been asked to pay $100 for the diagnostic services. The diagnostic service 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 myocardial perfusion imaging, tomographic (SPECT) (78452) provided May 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the breast ultrasound (76641 RT, LT) provided November 21, 2020
You asked the Plan to pay for the breast ultrasound. You say that please see records attached. The Plan denied your request. The Plan says the records do not support the billed support.
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 76641 is ultrasound, breast, unilateral, real time with image documentation, including axilla when performed, complete. We find that CPT code 76641 is not supported in the medical record. Specifically, the submitted medical record indicates the service was planned and that an ultrasound, breast, unilateral, real time with image documentation, including axilla when performed, limited was performed. There is a more appropriate CPT code (76642) for use to bill the service performed. The plan made multiple attempts to obtain additional information without success. Based on this information, we decided that Medicare rules for coverage of the breast ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the breast ultrasound (76641 RT, LT) provided November 21, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extension for skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are requesting an extension for SNF
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of
coverage were not 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled
nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a
daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve the extension for skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery performed at an outpatient
hospital on March 2, 2021.
You asked the Plan to waive the copayment for cataract surgery. You say that the service at issue should be
covered in full after a $100 copayment. 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 $390
copayment for outpatient surgery in an outpatient hospital.
You have been asked to pay a $390 copayment for cataract surgery. Cataract surgery falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 cataract surgery performed
at an outpatient hospital on March 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the morphometric analysis services coded 88377 provided on May 22, 2020 and May 23, 2020.
You asked the Plan to pay for the morphometric analysis 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. In this case, the CPT Code Manual definition of code 88377 is morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure. We find that CPT code 88377 is not supported in the medical record. Specifically, the enrollee has multiple myeloma. consistent with persistent/recurrent plasma cell neoplasia and/or myeloma in the context of the now
cytometry report and clinical history. Gain of 1 q is a high-risk prognostic marker in plasma cell myeloma. Per NCCI policy manual for Medicare Services Chapter X pathology/laboratory services: Medicare does not pay for duplicate testing. Immunocytochemistry (e.g., CPT codes 88342, 88341, 88344, 88360, 88361) and flow cytometry (e.g., CPT codes 88184-88189) should generally not be reported for the same or similar specimens. The diagnosis should be established using one of these methods. This means these services are not separately payable. Based on this information, we decided that Medicare rules for coverage of the morphometric analysis services have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis services coded 88377 provided on May 22, 2020 and May 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic Esophagogastroduodenoscopy (EGD) provided on January 13, 2021.
You asked the Plan to waive the copayment for the diagnostic EGD. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic EGD on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $250 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a diagnostic
EGD on January 13, 2021. You have been asked to pay a $250 copayment for the diagnostic EGD. The diagnostic EGD falls within the Outpatient surgery 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 the diagnostic Esophagogastroduodenoscopy (EGD) provided on January 13, 2021.
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's needs are being met in the current setting.
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 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the interrogation evaluation remote provided on January 25, 2021.
You asked the Plan to waive the copayment for the interrogation evaluation remote. You say that you did not see a doctor or nurse so you should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $35 copayment for Physician Services, Specialty Care Physician. You have been asked to pay $35 copayment for the interrogation evaluation remote. the interrogation evaluation remote falls within the Physician Services, Specialty Care Physician 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 the interrogation evaluation remote provided on January 25, 2021.
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 you are still unable to walk or stand for any length of time. The Plan denied your request. The Plan says you do not have any necessity for the level of care provided at an IRF.
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 you were admitted to the acute care hospital for Guillain-Barre syndrome and has been discharged home. There is ongoing weakness. Medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, and an intensive rehabilitation therapy program.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transportation services (A0428) received January 28 and February 2, 2021.
You asked the Plan to waive the copayments for the ambulance transportation services. You say that the requested services should be covered in full. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $225 copayment for each Medicare-covered service or one way trip by ground transportation .
You have been asked to pay $450 in copayments for the ambulance transportation services. You received two, one-way trips provided by ground ambulance. 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 copayments for the ambulance transportation services (A0428) received January 28 and February 2, 2021.
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 you will not receive the medical management and physical therapy you need at a skilled nursing facility. The Plan denied your request. The Plan says the IRF admission is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that you do 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. Our physician reviewer also found that there is not a reasonable expectation that you 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 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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care 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 that the enrollee is a 74-year-old woman who was admitted to an acute care hospital with hypoxic respiratory failure. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan.

You asked the Plan to pre-approve the CT scan. You say that the CT scan was necessary. The Plan denied your request. The Plan says the service was not shown to be medically necessary.

The Plan follows Medicare rules. Medicare rules say that CT scans are covered if there is literature to support its use for the patient's condition and the scan is reasonable and necessary for the patient. 

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 CT scan. Our reviewer says that the service is not medically necessary. Our physician reviewer found there was no specific clinical rationale for the requested CT scan of the lumbar spine. 

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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 12 additional routine transportation trips.
You asked the Plan to provide 12 additional routine transportation trips over the maximum. You say that you need 12 additional trips for appointments. The Plan denied your request. The Plan says you have 22 trips remaining and then you will have exceeded your benefit limit.
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 routine up to 52 one-way trips per calendar year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide 12 additional routine transportation trips over the maximum 52. You have not exhausted your maximum.