Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis (K0606) provided on August 28, 2020 by an out of network (OON) provider.

You asked the Plan to pay for automatic external defibrillator. You say that there's a deficient payment and you're requesting to have the claim reprocessed in network. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided 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 automatic external defibrillator, with integrated electrocardiogram analysis (K0606) provided on August 28, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), intraoral periapical radiographic images (D0220, D0230 x2), bitewing radiographic images (D0274), a teeth cleaning (D1110), and fluoride (D1206) provided on December 16, 2020.

You asked the Plan to pay an additional amount for a periodic oral evaluation), intraoral periapical radiographic images, bitewing radiographic images, a teeth cleaning, and fluoride. You say that you want the Plan to pay an additional amount towards the services at issue. The Plan denied your request. The Plan says the claims for these services were processed correctly with the applicable out-of-network allowable amount paid.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation), intraoral periapical radiographic images, bitewing radiographic images, a teeth cleaning, and fluoride have not been met. Specifically, the allowed amount of these services for an out-of-network provider were paid by the plan. Any amount beyond the allowed amount is your contractual responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for a periodic oral evaluation (D0120), intraoral periapical radiographic images (D0220, D0230 x2), bitewing radiographic images (D0274), a teeth cleaning (D1110), and fluoride (D1206) provided on December 16, 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 this is medically necessary. The Plan denied your request. The Plan says needed care can be safely given in a lower level of care, such as skilled or subacute nursing 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for aspiration pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skilled nursing facility (SNF) services
provided from November 1, 2020, to November 20, 2020.

You asked the Plan to waive the coinsurance for days 21-38 of the SNF services. You say that you cannot
afford the copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $178
copayment per day, days 21-100, for Skilled Nursing Facility Care.

You have been asked to pay a $178 copayment per day for days 21-38 of the SNF services. The SNF services
fall within the Skilled Nursing Facility 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 coinsurance
for the skilled nursing facility (SNF) services provided from November 1, 2020, to November 20, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on September 14, 2020, by an out of network provider.

You asked the Plan to pay for psychotherapy services. You say that the requested treatment was rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 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 psychotherapy services (90837) provided on September 14, 2020, by an out of network provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve panniculectomy and excessive skin removal with lipectomy.

You asked the Plan to pre-approve panniculectomy and excessive skin removal with lipectomy. You say that the requested panniculectomy and excessive skin removal with lipectomy are medically necessary. The Plan denied your request. The Plan says that the requested panniculectomy and excessive skin removal with lipectomy are not medically necessary.

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 in denying the request to pre-approve panniculectomy and excessive skin removal with lipectomy. Our reviewer says that the requested panniculectomy and excessive skin removal with lipectomy are medically necessary. Our physician reviewer found in this case; the enrollee is 4 feet nine inches tall. The pannus weighs approximately 37 pounds and images demonstrate coverage beneath mid-thigh. The enrollee has documented falls due to balance and is nearly non-ambulatory due to the pannus. The records indicate history of skin infection. The record supports the medical necessity and reasonableness as defined by Medicare rules of the requested service. The requested service is recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of panniculectomy and excessive skin removal with lipectomy have been met. Therefore, we decided that the Plan has to pre-approve panniculectomy and excessive skin removal with lipectomy.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is currently receiving appropriate care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 had network providers available who could have provided 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 psychotherapy services provided on September 10, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skilled Nursing Facility services.

You asked the Plan to pre-approve the Skilled Nursing Facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 Skilled Nursing Facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require the level of service provided in an inpatient Skilled Nursing Facility. The enrollee does not require skilled nursing or therapy services on a daily basis. 

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 Skilled Nursing Facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve Skilled Nursing Facility services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 28, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that the enrollee does not have a choice of which lab service to use. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 had network providers available who could have provided 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 laboratory testing provided on January 28, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on January 5, 2021.

You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says in order for medical services to be covered under your Plan they must be received from providers contracted with the Plan. The only exceptions to this are in cases of urgent or emergently needed care or if the medical care required cannot be provided by contracted, in-network providers and the Plan has given prior authorization for such care and kidney dialysis services obtained at a Medicare-certified dialysis facility when you are temporarily outside the Plan's service area.

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 vision services. 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 vision services provided on January 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87150 and 87801 provided on November 24, 2020.
You asked the Plan to pay for the laboratory 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. We find that CPT code 87150 and 87801 is not supported in the medical record. Specifically, the documentation did not include the laboratory results for the Culture, typing; identification by nucleic acid (DNA or RNA) probe or the Infectious agent detection by nucleic acid (DNA or RNA) services billed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87150 and 87801 provided on November 24, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 18, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on October 18, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound rendered on December 15, 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 76856 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 76856 is ultrasound, pelvic (nonobstetric), real time with image documentation; complete.

We find that CPT code 76856 is not supported in the medical record. Specifically, there is no documentation of a real time pelvic ultrasound with image documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound rendered on December 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on
June 15, 2020.

You asked the Plan to pay for the moderate sedation 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 99153 is moderate sedation services provided by the same physician or other qualified health care
professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence
of an independent trained observer to assist in the monitoring of the patient's level of consciousness and
physiological status; each additional 15 minutes intraservice time (List separately in addition to code for
primary service).

We find that CPT code 99153 is not supported in the medical record. Specifically, the documentation submitted
and claim form indicate this procedure was performed in a facility place of service of 24. Payment for this
service is included in payment to the facility and not separately reimbursable for this provider in this place of
service; therefore, the billed service cannot be supported. This code has a PC/TC Modifier Status = 3,
Technical component only codes: This indicator identifies standalone codes that describe the technical
component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code
that describes the professional component of the diagnostic tests only. Based on this information, we decided
that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided
that the Plan does not have to pay for the moderate sedation services coded 99153 provided on June 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection rendered on January 15, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. 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 a 20% coinsurance for Part B drugs that are administered by a provider.
Review of the file shows that you received a denosumab injection on January 15, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Part B drugs that are administered by a provider 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 for the denosumab injection rendered on January 15, 2021.