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

We decided that the Plan does not have to pay for dermatology services provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for dermatology services. You say that you were told that they took your insurance. The Plan denied your request. The Plan says prior authorization was not obtained. 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. Therefore, we decided that the Plan does not have to pay for dermatology services provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on January 2, 2020.
You asked the Plan to pay for the drug testing. 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 codes 80307 and G0480 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that LCA A57579 provides a list of non-covered codes. You can find this information in the
Local Coverage Article for Billing and Coding: MolDX: Multiplex Nucleic Acid Amplified Tests for
Respiratory Viral Panels (A57579).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health aide visits for the enrollee. You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the notes do not show a continued medical problem that needs special care that only a skilled person can do. The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the enrollee is not shown to require home skilled nursing services or home skilled therapy services. The enrollee is bedbound and requires total assist for ADLs. While the enrollee may require a caregiver, in the absence of skilled nursing or skilled therapy needs, a home health aide is not covered. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health aide visits for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on August 22, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation submitted did not include a complete physician order/lab requisition or medical records stating exactly what tests are to be performed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed." 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation submitted did not include a complete physician order/lab requisition or medical records stating exactly what tests are to be performed. It is noted multiple attempts were made to obtain additional information from the provider. The review indicates that the records do not support the coding of G0482. 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 not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the enrollee on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on February 12, 2020.You asked the Plan to waive the copayment forthe specialist office visit. You say that you never saw the doctor or a physician's assistant. You say you had a test done by a technician which was a separate claim. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered visit or consultation in an outpatient location with a specialist.You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you had an office visit and seen for urinary frequency/urgency/burning.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe specialist office visit on February 12, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0480) provided to the
enrollee on July 23, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0480 remains 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 HCPCS code G0480 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS
(any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic
methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in
all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method
or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument
variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing,
per day; 1-7 drug class(es), including metabolite(s) if performed."
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 the services. Our reviewer says that the
services at issue in this case were not coded correctly. Our physician reviewer found the prescribing physician
sent an order form indicating full presumptive screening drug testing on 1/15/2019 with reflexive definitive
testing. Screening test results were not provided to determine if reflex definitive testing was needed or
completed to help justify the use of the definitive drug testing code, G0480. Therefore, the provided records do
not support the coding of G0480.
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 not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services (HCPCS G0480) provided to the enrollee on July 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0480) provided to the enrollee on January 7, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe billed codes cannot be verified.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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of serviceHCPCS G0480:Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee's claim history indicates presumptive and or definitive services have been previously submitted by another provider for this date of service. In addition, the documentation submitted did not include a valid physician order/lab requisition or medical records. It is noted multiple attempts were made to obtain additional information from the provider. The review has determined that the provided records do not support the denied codes.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 not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services (CPT 80307 and HCPCS G0480) provided to the enrollee on January 7, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health nursing visits.You asked the Plan to pre-approvehome health nursing. You say that the enrollee is extremely fragile and requires weekly lab draws.The Plan denied your request. The Plan says venipuncture cannot be the sole reason for home health services.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receiveskilled nursing or therapy. A doctor must certify the need for home health care services.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 home health nursing. Our physician reviewer found that the enrollee is not shown to require in-home, skilled nursing services. There is no evidence of recent medication changes or a complex medication regimen. There is no evidence of a need for wound care. Venipuncture is not in-and-of itself considered a reason for skilled nursing service. The requested services are not shown to be medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health nursing have not been met. Therefore, we decided that the Plan does not have to pre-approvehome health nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visits and the
outpatient clinic visit provided from January 23, 2020 to February 19, 2020.
You asked the Plan to waive the copayments for the specialist office visits and the outpatient clinic visit. You
say that you cannot afford these copayments. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for in-network physician specialist services.
You have been asked to pay a $40 copayment for each of the specialist office visits and the outpatient clinic
visit. ($40 x 3 visits = $120). The specialist office visits and the outpatient clinic visit fall within the
"Physician/Practitioner services, including doctor's office visits" 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 copayments for the specialist office visits and the outpatient clinic visit
provided from January 23, 2020 to February 19, 2020.
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, as you require total assistance. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care, such as skilled nursing facility. 
 
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 you are medically stable and do not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While you are expected to benefit from continuing PT and OT, 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve18 additional home health care visits.You asked the Plan to pre-approve18 additional home health care visits. You say that you need assistance.The Plan denied your request. The Plan says you have natural supports in the home to assist with care.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 18 additional home health care visits. Our reviewer says that the requested visits are not medically necessary. Our physician reviewer found you are not shown to require in-home, skilled nursing services, multiple times a week. You are noted to have a small, healing toe ulcer. Wound care appears to consist of a simple wet-to-dry dressing thrice weekly. The documentation does not show an inability to tend to the wound or a need for wound monitoring beyond the regularly scheduled wound clinic visits or intermittent home visits. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 18 additional home health care visits have not been met.Therefore, we decided that the Plan does not have to pre-approve18 additional home health care visits.
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 would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission is not medically necessary.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 underwent left hip repair. The enrollee required minimal assistance times two to stand up and sit down. The documentation does not support that the enrollee requires the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard provided on March 19, 2020.
You asked the Plan to pay for the occlusal guard. You say that specialists recommended this because you were
having trouble with the CPAP machine. You say that this was medically necessary. The Plan denied your
request. The Plan says the service is not a covered benefit.
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
occlusal guard provided on March 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiac rehab services provided on February 3, 2020 to February 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the medical records warrant the medical necessity of the service billed. The Plan denied your request. The Plan says prior 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 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 cardiac rehab services provided on February 3, 2020 to February 28, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 18, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 drug testing rendered on June 18, 2019.