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

We decided that the Plan does not have to pay for the medical services provided on October 24, 2019 by an out of network (OON) provider. You asked the Plan to pay for outpatient clinic services. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service. 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 has network providers available who can provide 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 medical services provided on October 24, 2019 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 medical services provided to the enrollee on January 15, 2019. You asked the Plan to pay for the services provided. You say that the services were not rendered or offered by the facility. The Plan denied your request. The Plan says the billed place of service is not supported. The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. This means that payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on January 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the lumbar spine (72100) provided on June 18, 2019. You asked the Plan to pay for the office visit and the x-ray exam of the lumbar spine. You say that the
chiropractic treatment provided was medically necessary. The Plan denied your request. The Plan says these services provided are not a covered benefit under your contractual policy. 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 for the office visit (99203) and the x-ray exam of the lumbar spine (72100) provided on June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on April 16, 2019.
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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered to the enrollee on April 16, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an electrocardiogram (93010) provided on July 8, 2019. You asked the Plan to pay for the electrocardiogram. You say that these services were medically necessary and provided prior to the member's date of death. The Plan denied your request. The Plan says that these services were rendered after the member's date of death. The Plan must follow Medicare rules. Medicare rules say that coverage ends with the beneficiary's death. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have been met. Specifically, the Plan has provided a death certificate which indicates these services were rendered prior to the member's date of death. Therefore, we decided that the Plan has to pay for an electrocardiogram (93010) provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye refraction services you received on November 6, 2019.
You asked the Plan to pay for the services provided. You say that as a diabetic, you have two eye exams a year. The Plan denied your request. The Plan says you already used the benefit this calendar year. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The records show that you received eye refraction services on April 16, 2019. Your plan only covers refraction services once per calendar year. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye refraction services you received on November 6, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for nursing facility care (99309) provided on August 10, 2019. You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this is health Plan responsibility due to out of area services. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There is insufficient information to substantiate the Plan's denial of services. Therefore, we decided that the Plan has to pay for nursing facility care (99309) provided on August 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on October 9, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the place of service on the claim form must reflect the location the specimen was obtained. The Plan must follow Medicare rules. Medicare rules say that the place where the sample was taken is reported as the Place of Service. We looked at the file and the rules. The records provided do not show that the specimen at issue was taken at an independent lab. 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 the lab services provided to the enrollee on October 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 17, 2019 to the enrollee by an out of network (OON) provider. 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 were rendered by a non-network provider without 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 referring provider 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. 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 medical services provided on October 17, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on November 5, 2019. You asked the Plan to pay for drug test. You say that this testing was deemed medically necessary by the ordering physician, and it was not the responsibility of your laboratory to create a treatment plan or have any contact with the enrollee. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test exceeds the maximum covered frequency of 18 tests per year.
The Plan must follow Medicare rules. Medicare rules say that the frequency of presumptive urinary drug testing may be limited to 156 times per year for enrollees with 0 to 90 consecutive days of abstinence or 36 times per year for enrollees with more than 90 consecutive days of abstinence. We looked at the file and Medicare rules. Our review of the rules did not reveal a limitation of 18 tests per year for these services, as cited by the Plan. The Plan has not shown that this test exceeded the frequency limitation for presumptive urinary drug testing as cited above in the LCD. Based on this information, we decided that Medicare rules for coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug testing provided on November 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 1, 2019 to the enrollee by an out of network (OON) provider. 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 were rendered by a non-network provider without 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 referring provider 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. 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 medical services provided on November 1, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 16, 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 billed services were not supported by the records. The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on May 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care provided on November 29, 2019 and November 30, 2019. You asked the Plan to pay for the subsequent hospital care. You say that the services rendered were unrelated to the enrollee's hospice care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition. Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on November 28, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care provided on November 29, 2019 and November 30, 2019.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 currently undergoing treatment at an acute care hospital (ACH) for pneumonia, acute-on chronic renal injury and an ankle fracture. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 pay for the radiology services provided on October 15, 2019 by an out of network (OON) provider. You asked the Plan to pay for the out of network radiology services. You say that the records provided support the services in dispute. The Plan denied your request. The Plan says the practice is a non-network provider with the enrollee's health plan. The Plan says that the enrollee was referred by a non-participating 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 has network providers available who can provide 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 radiology services provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient staywith an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay formedical supplies (HCPCS A7048) provided to the enrollee on April 12, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysHealthcare Common Procedure Coding System (HCPCS)code A7048 (15 Units) remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the CPT Code Manual definition of HCPCS A7048 is "Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each."We find that HCPCS code A7048 is not supported in the medical record. Specifically, there is no records of a itemized shipping/billing invoice to verify the denied supplies. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay formedical supplies (HCPCS A7048) provided to the enrollee on April 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an electrocardiogram (93010) provided on July 12, 2019.You asked the Plan to pay for the electrocardiogram. You say that according to the death summary, the date of death is July 12, 2019 nit July 5, 2019. The Plan denied your request. The Plan says that the billed date of service is after the date of death onfile.The Plan must follow Medicare rules. Medicare rules say that if not terminated sooner, coverage ends with the beneficiary's death. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe electrocardiogram have been met. Specifically, the Plan has provided a death certificate which indicates the member's date of death was July 12, 2019. The billed services were rendered prior to the member's date of death. Therefore, we decided that the Plan has to pay for an electrocardiogram (93010) provided on July 12, 2019. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network ear, nose, and throat (ENT) specialist.You asked the Plan to pre-approvethese services. You say that you have a serious case of tinnitus.The Plan denied your request. The Plan says the services are available from network providers.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-approvea referral to an out-of-network ear, nose, and throat (ENT) specialist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on February 18, 2019 by an out of network provider.You asked the Plan to pay forthe ambulance services. You say that the hospital should have coordinated with the Plan for an authorization.The Plan denied your request. The Plan says prior authorization was not requested.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 carefrom 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 has network providers available who can provide 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 ambulance services providedon February 18, 2019 by an out of network provider.