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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 medical services provided to the enrollee by an out-of-network provider on August 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided on July 28, 2019.You asked the Plan to waive the copayment for an ambulance trip. You say that you did not request the ambulance and disagree with 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 $225 copayment for ambulance services.You have been asked to pay a $225 copayment for an ambulance trip.An ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided on July 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond February 8, 2020
You asked the Plan to pre-approve these services. You say that the enrollee needs continued physical therapy. The Plan denied your request. The Plan says the continued services are not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF after hospitalization with an open reduction, internal fixation (ORIF) on January 2, 2020. She needs contact guard assist with toileting transfers and modified assist with lower body bathing and dressing. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond February 8, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on April 22, 2019.
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the medical records from the enrollee's office visit do not support an ankle foot orthosis was necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medical necessity is not supported in the medical records. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis (L1971) have not been met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis provided on April 22, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from March 14, 2019 through April 8, 2019.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says their records show they do not have a valid referral for this service. The Plan states if there is no valid referral, the enrollee is responsible for this charge and if a valid referral is received the Health Plan will reconsider this charge.
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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. The Health Plan did receive an authorization request on March 11, 2019, for the Skilled Nursing stay. Authorization #512698401000 was denied due to the request not meeting criteria, and a letter was generated and mailed to the enrollee on March 13, 2019. The Health Plan received the appeal without medical records to help justify the inpatient stay at the Skilled Nursing facility. The Health Plan has made several attempts to the various resources possible to request and obtain records. At the time of decision, no records were received. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from March 14, 2019 through April 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 31, 2019
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 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 laboratory services provided on January 31, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anal/urinary muscle study, muscle test nonparaspinal,
somatosensory testing, central motor evoked potential study, and continuous intraoperative neurophysiology
monitoring provided on November 25, 2018.
You asked the Plan to pay for the studies, tests, and monitoring services. You say that you sent a corrected
claim with modifier GW. You also say that GW is the modifier that should be used when a service is rendered
to an enrollee who is enrolled in a hospice and the service is unrelated to the enrollee's terminal condition. 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. 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 anal/urinary muscle study, muscle test nonparaspinal,
somatosensory testing, central motor evoked potential study, and continuous intraoperative neurophysiology
monitoring provided on November 25, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from April 9, 2019 to May 21, 2019.You asked the Plan to pay forhome infusion therapy. You say that you should be reimbursed for this service.The Plan denied your request. The Plan says the billed CPT code is invalid for Medicare purposes.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, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from April 9, 2019 to May 21, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician certification (G0180) provided on August 16, 2019.
You asked the Plan to pay for the physician certification. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a secondary only diagnosis cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.
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 G0180 is not supported in the record. Specifically, the Primary Diagnosis in this case is F07. F07 is a "Code first" code, which means that the underlying condition should be sequenced first. In this case, the underlying conditions were known but were not sequenced first. Based on this information, we decided that Medicare rules for coverage of the physician certification have not been met. Therefore, we decided that the Plan does not have to pay for physician certification (G0180) provided on August 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe genetic testing rendered to you on September 16, 2019.You asked the Plan to waive the coinsurance fortheseservices. You say that you shouldn't be liable.The Plan denied your request. The Plan says the coinsurance was 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 20% of the Medicare-allowed amount for each in-network Medicare-covered genetic test. Review of the file shows that you received genetic testing on September 16, 2019. You have been asked to pay 20% of the Medicare-allowed amount for these services, for a total of $774.60. These services fall within the in-network Medicare-covered genetic test 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 coinsurance forthe genetic testing rendered to you on September 16, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another setting.
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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, O2 care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 19, 2019 by an out of network provider.
You asked the Plan to pay for the non-emergent ambulance services. 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 for the ambulance services provided on July 19, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric Oxygen therapy (G0277) provided September 23, 2019 to September 26, 2019.
You asked the Plan to pay for the hyperbaric Oxygen therapy. You say that you request reconsideration and the records should support the necessity of the services. The Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the plan.
The plan covers all items that Medicare covers. Medicare rules say that hyperbaric oxygen therapy is not covered. Based on this information, we decided that Medicare rules for coverage of the hyperbaric Oxygen therapy have not been met. Therefore, we decided that the Plan does not have to pay for hyperbaric Oxygen therapy (G0277) provided September 23, 2019 to September 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision of excessive abdominal skin and subcutaneous tissue (panniculectomy)(15830).
You asked the Plan to pre-approve a panniculectomy. You say that this is medically necessary due to risk of infection. The Plan denied your request. The Plan says the records fail to document the presence of ongoing infections and failed medical attempts to control infections.
The Plan follows Medicare rules. Medicare rules say that panniculectomy will be considered medically necessary when the pannus or panniculus hangs below the level of the pubis, and the medical records document that the panniculus causes chronic intertrigo. 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 a panniculectomy. Our reviewer says that Medicare criteria for coverage of this procedure have not been met. Our physician reviewer found there are no medical chart notes documenting any infections or treatments. The submitted pictures do not show any sign of active infection. It is also unclear if the patient is weight stable for six months based on the submitted medical 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 a panniculectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve the excision of excessive abdominal skin and subcutaneous tissue (panniculectomy)(15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forknee orthosis (L1851 RT) and suspension sleeve (L2397RT) provided by "the provider" on February 13, 2019.You asked the Plan to pay forthe orthoses. You say that the supplies provided were medically necessary and should be covered by the plan.The Plan denied your request. The Plan says this item was billed more than the frequency allowance.The Plan must follow Medicare rules. Medicare rules say that The reasonable useful lifetime of DME or prosthetic and orthotic devices is determined through program instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of equipment but in no case can it be less than 5 years. There is no evidence that the orthoses that the enrollee received in February 8, 2019 were lost, stolen, or destroyed, coverage is not allowed for replacement of the braces. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1851 RT) and suspension sleeve (L2397RT) provided by "the provider".
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHerceptin.You asked the Plan to pre-approveHerceptin. The Plandenied your request. The Plan says this drug it not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Herceptin. Our reviewer says that Herceptin is not medically reasonable and necessary.Our physician reviewer found that the enrollee is an 88-year-old woman with recurrent HER2 positive salivary gland cancer from the parotid. The office note of January 21, 2020, indicates she has performance status of 4 on the ECOG scale. MRI showed stabledisease on September 24, 2019, and normal cardiac ejection fraction on September 25, 2019. The NCCN compendium supports the use of Herceptin for treatment for human epidermal growth factor receptor 2 (HER2)-positive recurrent disease with distant metastases in patients with a performance status (PS) of 0-3. The submitted documents indicate that the enrollee's performance status is 4. However, the note indicates she cannot use her walker because of a wrist fracture and the cast is due to be removed. It is not known what her performance status was prior to the fracture or what it will be after the cast is removed. Therefore, the documentation does not support that the drug is reasonable and necessary to treat the enrollee. The documentation does not support that the drug is safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Herceptin have not been met.Therefore, we decided that the Plan does not have to pre-approveHerceptin.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approvetransthoracic echocardiography with Doppler complete for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis was denied due to a lack of medical necessity.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 indenying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee reports palpitations and has PACs on her baseline ECG.She has a history of rheumatoid arthritis which puts her at risk for various types of rheumatoid heart disease which can include cardiac muscular, vascular and valvular structural abnormalities of the heart as a cause of palpitations. A single transthoracic echocardiogram with Dopplervalve interrogation is therefore both reasonable and medically necessary to assess cardiac structure and valve function given her symptoms of palpitations and her history of rheumatoid arthritis, which increases her risk for various structural heart abnormalities.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 services have been met.Therefore, we decided that the Planhas to pre-approvetransthoracic echocardiography with Doppler complete for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided by an out of network provider on March 4, 2019.
You asked the Plan to pay for these services. You say that the hospital obtained authorization for the services, however, the authorization did not begin until March 5, 2019. The Plan denied your request. The Plan says the services were not prior authorized, therefore are not covered.
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 has network providers available who can provide 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 subsequent hospital care (99232) provided by the out of network provider on March 4, 2019.