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

We decided that the Plandoes not haveto pre-approve admission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe SNF admission. You say that you believe that a short stay in the facility with daily PT would help you regain strength and return to your prior level of function.The Plandenied your request. The Plansaysyou only require minimal assistance and do not require daily therapy to maintain this functional level or to improve.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 beneficiary is a 92 year old woman with CKD, renal cancer, atrial fibrillation ad diabetes admitted to the hospital with nausea, vomiting and diarrhea. From a nursing perspective, the beneficiary received oral and topical medications and insulin. The beneficiary had stable vital signs. Her lungs were clear.Regarding rehabilitation services, the beneficiary received PT and OT in the acute hospital. The beneficiary was at a stand by assist to contact guard assist level for functional mobility including gait to 75 feet with a rolling walker. The beneficiary required varying assist with ADLs.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but the enrollee does not need to have therapy on a daily basis. This beneficiary 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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has worsening symptoms. The Plan denied your request. The Plan says the services are not medically necessary.
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 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 secondary complaint of low back pain. Physical findings did not reveal any signs of a significant radiculopathy or other red flag diagnosis to warrant MRI of the lumbar spine. There is also insufficient detail documented regarding current and prior attempts at conservative care including exercises for the lumbar and leg symptoms. There is no planned procedure that may warrant imaging. The MRI is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0483) provided on November 2, 2018.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the member's primary care physician did not issue a referral for these services. The health plan requires utilization of network providers when possible and available, and requires prior authorization for services rendered by 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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. The plan has network providers available that can provide the services at issue in this appeal. 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 hospital outpatient clinic visit (G0483) provided on November 2, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on February 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered as an outpatient procedure.The Plan must follow Medicare rules. The rulessay that CMS does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient.We looked at the file and Medicare rules. The file shows that procedure code 67027 (implantation ofintravitreal drug system) was billed as an outpatient procedure. This code is on the inpatient-only list for the year 2019. 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 forthe surgical services rendered on February 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on June 5, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary carrier's Explanation of Benefits was not received.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided to enrollee on June 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 21, 2019 by an out of network provider.
You asked the Plan to pay for physician services. You say that you would like this appeal to be considered retro-authorization for the concerned patient. The Plan denied your request. The Plan says these services were member self-directed. The Plan says that the member's primary care physician did not refer 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. There is no network deficiency for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on June 21, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the complex repair services coded 13121 provided on July 15, 2019.
You asked the Plan to pay for the complex repair services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 13121 is Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm. We find that CPT code 13121 is not supported in the medical record. Specifically, the submitted documentation does not indicate that repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm was performed; therefore, the billed service cannot be verified. The submitted documentation indicate that simple repair of scalp wound measuring 7cms in length was performed. Based on this information, we decided that Medicare rules for coverage of the complex repair services have not been met. Therefore, we decided that the Plan does not have to pay for the complex repair services coded 13121 provided to enrollee on July 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (73564) provided on August 8, 2019 by the out of network hospital.
You asked the Plan to pay for an x-ray. You say that this service was medically necessary. The Plan denied your request. The Plan says this service was not authorized.
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 an x-ray (73564) provided on August 8, 2019 by the out of network hospital.
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 you are appealing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician 3 times per week or acute rehabilitation nursing care. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on August 16, 2018.
You asked the Plan to pay for ambulance services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says Original Medicare is responsible for this claim.
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. Enrollee ended Medicare Hospice benefits on August 16, 2018. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for services provided on August 16, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 14, 2019 through September 21, 2019.
You asked the Plan to pay for the home infusion therapy. You say that S9328 is a valid code per CMS. The Plan denied your request. The Plan says Medicare guidance says procedure code S9328 has a status code of "I."
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 S9328 is not supported in the medical record. Specifically, per the 2019 Physician Fee Schedule, S9328 has a status code of I. This means that S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy. have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 14, 2019 through September 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services during the knee arthroplasty provided on July 9, 2019.
You asked the Plan to pay for the surgical assistant services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not payable.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services during the knee arthroplasty provided on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 1, 2019 to October 20, 2019.You asked the Plan to pay forthe diabetic supplies. The Plan denied your request. The Plan says that valid proof of delivery was not submitted.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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 1, 2019 to October 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CPAP supplies provided on August 13, 2019 by out of network provider. You asked the Plan to pay forthe CPAP supplies. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not request 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 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 forthe CPAP supplies provided on August 13, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 10, 2019 to June 20, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you were discharged too early and should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $195 copayment for days1-5 for inpatient hospital care. You had an inpatient hospital stay from June 10, 2019 to June 20, 2019. Therefore, you are responsible to pay a $195 copayment for days 1-5 (June 10, 2019 to June 14, 2019). $195 (copayment) x 5 (inpatient days) = $975.00.You have been asked to pay the total copayment amount of $975.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 foran inpatient hospital stay from June 10, 2019 to June 20, 2019.Your quality of care concerns have been handled separately by the health plan. Medicare does not permit us to make a decision on this type of complaint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on August 16, 2019 by out of network provider.

You asked the Plan to pay for an office visit. You say that you are appealing claim payment denial for services rendered to your member on date of service August 16, 2019. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 an office visit (99203) provided on August 16, 2019 by out of network doctor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV therapy, drugs, and laboratory services provided on July 24, 2019.You asked the Plan to pay for the IV therapy, drugs, and laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee was enrolled in hospice for this date of service.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the IV therapy, drugs, and laboratory services provided on July 24, 2019.Please note: The services provided to the enrollee from July 20, 2019 to July 23, 2019 is being addressed under a separate case.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve tadalafil 5mg tablets.
You asked the Plan to pre-approve the tadalafil tablets. You say that the enrollee needs this medication. The Plan denied your request. The Plan says this oral drug cannot be covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve tadalafil 5mg tablets.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a microscopic genetic analysis of a tumor (88360) provided
on March 19, 2019 by an out of network provider.
You asked the Plan to pay for a microscopic genetic analysis of a tumor. You say that you are a nonparticipating
provider who is appealing the claim for date of service March 19, 2019. You say that the claim
was denied for no authorization on file. You are requesting a review and the payment. The Plan denied your
request. The Plan says the practice is a non-network provider who does not work with the member's
health plan, and the member was referred by a doctor who also does not work with the member's
plan. The member's primary care physician did not refer for services. The health 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 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 a microscopic genetic analysis of a tumor (88360)
provided on March 19, 2019 by the out of network provider.