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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that it is felt that the enrollee should continue with daily skilled care due to her condition. The Plan denied your request. The Plan says the documentation does not support that the enrollee requires daily skilled nursing or therapy services to maintain her condition or prevent deterioration.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a bedbound female who was admitted to the hospital with acute encephalopathy, seizures, atrial fibrillation, and aspiration pneumonia. She required intubation but was successfully extubated.
This patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The patient does not have a complex wound care or other SNF level skilled nursing need. This patient's functional level is near baseline and does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment. The patient does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this patient does not require the necessary services on an SNF level. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe Baha power processor and the Baha Transducer from an out-of-network provider. You say that the provider does not provide Baha services. You say that the provider is the only company that can provide this required equipment.The Plan denied your request. The Plan says they have outreached to the provider services and they can provide the Baha 5 power compressor and Baha transducer being requested. The plan says that there is not a network deficiency.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-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from July 20, 2019 to July 30, 2019.
You asked the Plan to pay for the services. You say that you thought that this provider was in-network. The
Plan denied your request. The Plan says there was no authorization for these services.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for chiropractic services provided from July 20, 2019 to July 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forComputed Tomography (CT) of the abdomen and pelvis (74176) on October 11, 2019.You asked the Plan to pay forthe CTscan. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim submitted included duplicate coding for the service at issue.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 74176 is not supported in the medical record. Specifically, the claim includes separate codes for the professional and technical components, as well as a code for the global procedure. The code for the global procedure has already been allowed by the plan. Billing for the technical and professional components (26 and TC modifiers) is duplicative. 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 pay forComputed Tomography (CT) of the abdomen and pelvis (74176) provided on October 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (CPT 97110, CPT 99213) you received from September 4, 2019, to October 1, 2019.You asked the Plan to pay forthe chiropractic services. The Plandenied your request. The Plan says this is not a covered service when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (CPT 97110, CPT 99213) you received from September 4, 2019, to October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased from the facility on December 1, 2019.
You asked the Plan to pay for hearing aids. You say that you received a quote from the in network provider and determined you would pay less by obtaining the hearing aids from the facility. The Plan denied your request. The Plan says hearing aids purchased from out of network providers are not covered by the plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only hearing services and hearing aids are covered only when rendered by a participating provider. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased from the facility on December 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2781) and standard frames (V2020) purchased on September 18, 2019.
You asked the Plan to pay for the eyeglasses. You say that you do not understand what the status of the doctor has to do with this issue and is not going to take up his time sharing a copy of this decision with him. The Plan denied your request. The Plan says vision services must be obtained from a participating provider.
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. The Plan covers routine eye exams and eye wear is covered when provided by a plan participating provide.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for progressive lens (V2781) and standard frames (V2020) purchased on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the optometry visit provided on October 7, 2019.
You asked the Plan to waive the copayment for the optometry visit. You say that you should not be responsible for the copayment because the visual field exam could not be done on the August 21, 2019 visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $30 copayment for subsequent visits for in-network eye exams either Medicare-covered or routine. You have been asked to pay a $30 copayment for the optometry visit. The optometry visit falls within the "Vision care" benefit category. The record shows this was a subsequent visit.
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 optometry visit provided on October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay foran ultrasound of the breast (76641) provided August 5, 2019.You asked thePlan to pay forcode 76641. You say that you would like reconsideration based on the medical records provided.The Plan denied your request. The Plan says the medical records do not contain sufficient documentation to support the procedure codes level of complexity.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 asked our coder 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 code 76641. Our reviewer says that an ultrasound of the breast (76641) is not supported by the medical records. Our coder reviewer found description ofan Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete includes examination of all four quadrants of the breast, as well as the retroareolar region. The medical records provides do not include a report of the retroareolar region, therefore, it is inappropriate to use CPT code 76641 to represent the services at issue.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 76641 have not been met. Therefore, we decided that the Plan does not have to pay foran ultrasound of the breast (76641) provided August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided August 19, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services 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 for physician's services provided August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 5, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on June 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Planhasto pay for inpatient acute hospital admission for the enrollee.You asked the Planto pay foracute inpatient hospital care. You say that this is medically necessary.The Plandenied your request. The Plansaysthathospital observation services can be approved.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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. His condition stablized and improved and he was discharged home when considered medically stable on 1/7/20.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 havebeen met.Therefore, we decided that the Planhas to pay forinpatient acute hospital admission for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 26, 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 he medical necessity for the special stain or IHC studies, and the results of the stain or IHC, must be documented in the surgical pathology report.
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 88312 is "Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver)." 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 coded correctly. Our coding reviewer found there is no medical documentation provided that includes documentation of and services provided on September 26, 2019 for the enrollee, therefore, the services cannot be verified. 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 lab services provided to the enrollee on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health aide and skilled care services.You asked the Plan to pre-approvethe home health services. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found that the records do not show that skilled nursing services or skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. There are no skilled nursing needs such as new enteral feeding, a new tracheostomy tube, intravenous medications, complex wound care. Without the need for skilled nursing or skilled therapy services the services do not meet the definition of home health aide services per Section 50.2. Home health aide services are not reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff.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 home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health aide and skilled care services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto.You asked the Plan to pre-approve Stiolto. You say that the enrollee cannot use alternative medications.The Plan denied your request. The Plan says this is not a Part B drug.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveStiolto.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity (73718).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.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 MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if thePlan was correct in denying the request to pre-approve the MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found a detailed physical examination noting abnormalities or a differential diagnosis is not included.  Without the support of the documentation, medical necessity cannot be determined.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the lower extremity (73718).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab work provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 foroutpatient lab work provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on September 18, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that the procedure was incomplete. You say that you shouldn't have to pay a copayment.The Plan denied your request. The Plan says the copayment 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 $200 copayment per date of service for outpatient surgery at an ambulatory surgical center.You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The recordsshow that the colonoscopy was performed. 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 forthe colonoscopy provided on September 18, 2019.