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

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve office visits. You say that this request is medically necessary. The Plan denied your request. The Plan says they have multiple in-network providers available to provide for the enrollee's medical needs.
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 office visits to be provided by an out of network (OON) provider.
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 need to regain mobility. The Plan denied your request. The Plan says you do not need to be seen by a rehab doctor at least 3 times a week, or 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 you were admitted to the acute care hospital for weakness and have been discharged home with home health services. Your medical conditions are stable. There are no complex nursing needs. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sort-latency somatosensory evoked potential study coded 95938, the needle electromyography coded 95861, the sterile needle coded A4215, the neuromuscular junction testing coded 95937 and the continuous intraoperative neurophysiology monitoring in the operating room provided on October 27, 2020.
You asked the Plan to pay for the sort-latency somatosensory evoked potential study, the needle electromyography coded 95861, the sterile needle, the neuromuscular junction testing and the continuous intraoperative neurophysiology monitoring in the operating room. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 codes 95938, 95861, A4215, 95937 and 95940. are not supported in the medical record. Specifically, the billed place of service 15 (mobile unit) billed with codes 95938 and 95861 is not supported by the documentation. The documentation supports that the enrollee received the services in a facility setting. Medicare rules say that CMS does not separately pay any provider or supplier other than the facility in the prospective payment system (PPS) for services furnished to the beneficiary in preparation for, during, or following a procedure or surgery. The facility must furnish all necessary covered services to the enrollee either directly or under arrangements made between the facility and outside vendors. The enrollee received the services during or in preparation for a procedure or surgery. at the facility. Payment for this service would be included in the facility PPS payment. Based on this information, we decided that Medicare rules for coverage of the sort-latency somatosensory evoked potential study, the needle electromyography coded 95861, the sterile needle, the neuromuscular junction testing and the continuous intraoperative neurophysiology monitoring in the operating room have not been met. Therefore, we decided that the Plan does not have to pay for the sort-latency somatosensory evoked potential study coded 95938, the needle electromyography coded 95861, the sterile needle coded A4215, the neuromuscular junction testing coded 95937 and the continuous intraoperative neurophysiology monitoring in the operating room provided on October 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGM supply allowance provided on December 10, 2020.
You asked the Plan to pay for the CGM supply allowance (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code, nor did documentation indicate the provider discussed the need for the billed supply code.
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, or relevant medical records which support medical necessity for the supplies provided in this case. There is no delivery ticket nor proof of delivery and the medical records do not show the enrollee uses a CGM. There is no medical record for the date of the physician order. 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 CGM supply allowance provided on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the OON provider on
March 18, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal.
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 the laboratory services rendered
by the OON provider on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injections provided on January 7, 2021 and January 13, 2021
You asked the Plan to pay for injection, vitamin b-12 cyanocobalamin, up to 1000 mcg (J3420), Unclassified drugs (J3490), and injection, levocarnitine, per 1 gm (J1955). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were experimental and investigational.
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 pay for injection, vitamin b-12 cyanocobalamin, up to 1000 mcg (J3420), Unclassified drugs (J3490),and injection, levocarnitine, per 1 gm (J1955). Our reviewer says that the injections are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/ investigational therapy. Therefore, the injections were not medically 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 injection, vitamin b-12 cyanocobalamin, up to 1000 mcg (J3420), Unclassified drugs (J3490), and injection, levocarnitine, per 1 gm (J1955) have not been met. Therefore, we decided that the Plan does not have to pay for the injections provided on January 7, 2021 and January 13, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 18, 2020.
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 procedure code 27365 is not supported.
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 27365 is radical resection of tumor, femur or knee. We find that CPT code 27365 is not supported in the medical record. Specifically, there is no documentation of a radical resection of a tumor of the femur or knee. 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 surgical services rendered on August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve erbium laser treatment.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that removal of skin lesions is covered when specific
criteria are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee had a facial melanoma
removed and underwent a skin graft. The graft has a discrepancy of sebaceousness with the native skin. The
requested laser treatment is not reasonable or medically necessary based on the submitted records.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve erbium laser treatment.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 14, 2020.
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 procedure codes 81407, 81406, 81408, and 81404 are not supported.
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 codes 81407, 81406, 81408, and 81404 are not supported in the medical record. Specifically, there is no documentation of any services rendered for the date of service at issue. 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 laboratory services rendered on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic exam of voice box using a flexible endoscope (31575) and Botox injection (J0585) provided May 7, 2020.
You asked the Plan to waive the cost share for the diagnostic exam of voice box using a flexible endoscope and Botox injection. You say that you believe you are being charged an incorrect cost share. The Plan denied your request. The Plan says the cost share has processed correctly for these claims.
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 20% coinsurance for Medicare Part B prescription drugs and a.
You have been asked to pay a total cost share of $294.40 for the diagnostic exam of voice box using a flexible endoscope ($50 copayment) and Botox injection ($1222 x 20% coinsurance). These services fall within the Medicare Part B prescription drugs and diagnostic exam 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 cost share for the diagnostic exam of voice box using a flexible endoscope (31575) and Botox injection (J0585) provided May 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device. You say that the enrollee urgently needs the requested device, as it will allow betting monitoring and management of the enrollee's symptoms that lead to repeat heart failure hospitalizations. The Plan denied your request. The Plan says the requested implantable wireless pulmonary artery pressure sensor with delivery catheter is not medically necessary.
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 the CardioMEMS device. Our reviewer says that the CardioMEMS device is not considered medically reasonable and necessary in this case. Our physician reviewer found the record states that the enrollee has heart failure and is receiving palliative milrinone. He has had surgical procedures due to pulmonary atresia and ventricular septal defect. The record states that the enrollee does not have shortness of breath or worsening dyspnea on exertion. He is walking his dog without difficulty. At the time of his admission for exacerbation of heart failure he was classified as a NYHA IIIa. The record does not credibly indicate a baseline NYHA classification of III.
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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires intensive skilled
services that are not available at a lower level of care. The Plan denied your request. The Plan says the enrollee
does not need to be seen daily by a physician.
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 physician
reviewer found that the enrollee was admitted to the acute care hospital after a motor vehicle accident. The
enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. Therefore, the requested LTACH services are not. 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on October 7, 2020.
You asked the Plan to pay for home health services. You say that this claim was re-billed correctly. The Plan denied your request. The Plan says this claim was billed with an incorrect type of bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this date of service was not billed with the correct type of bill. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee on October 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for this
enrollee. The Plan denied your request. The Plan says the enrollee's condition does not meet all the
requirements for admission to an IRF, and the necessary services can be safely provided at a lower level of
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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to adjust the amount paid for services provided on January 4, 2021.
You asked the Plan to adjust the amount paid for the services. You say that the fees submitted certainly do not exceed the normal amount for this type of specialization. The Plan denied your request. The Plan says the claim was processed correctly according to the customary allowable amount.
The Plan must follow Medicare rules. Medicare rules say that physicians are paid according to the MPFS. We looked at the file and Medicare rules. If a doctor or supplier accepts Medicare assignment, this means that they agree to accept the Medicare-approved amount for a service or item as payment in full. The Medicare-approved amount could potentially be less than the actual amount a doctor or supplier charges, depending on whether or not they accept Medicare assignment. Non-participating providers are paid 95% of the fee schedule amount.
Based on this information, we decided that Medicare rules for coverage of the amount paid for services have been met. Therefore, we decided that the Plan does not have to adjust the amount paid for services provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) provided on March 9, 2021.
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that your provider felt this film had to be taken due to extenuating circumstances. You also say that the procedure could not have been performed without this technology being exercised. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on February 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on February 15, 2021.