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

We decided that the Plan does not have to pay for laboratory services provided on December 20, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the 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 did not pre-approve the
laboratory 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 laboratory services provided on December 20, 2019.
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 the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical
records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that
you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more
appropriate in this case.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 22, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 15734 and 14301 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 15734 is muscle, myocutaneous, or fasciocutaneous flap;
trunk. The definition of code 14301 is adjacent tissue transfer or rearrangement, any area; each additional 30.0
sq. cm, or part thereof (List separately in addition to code for primary procedure).
We find that CPT codes 15734 and 14301 are not supported in the medical record. Specifically, the operative
report does not include documentation of a muscle, myocutaneous, or fasciocutaneous flap from the trunk to
support code 15734. The operative report does not include documentation of an adjacent tissue transfer to
support code 14301. Based on this information, we decided that Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered
on January 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing rendered on January 20, 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 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. Please note that the Plan has stated that you are not financially responsible for the services. Therefore, we decided that the Plan does not have to pay for the genetic testing rendered on January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) provided on March 17, 2020.You asked the Plan to pay forthe problem focused limited oral evaluation. You say that this service was to evaluate pain around the gums and in the tooth next to the area where you had a root canal removed in the past.The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation on January 6, 2020 and your problem focused limited oral evaluation (D0140) benefit has been exhausted.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation (D0140) provided on March 17, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 3, 2020 by an out of network (OON) provider.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 the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 medical services provided on March 3, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99231) provided on October 31, 2019.You asked the Plan to pay for subsequent hospital care. You say that this service was subsequent care.The Plan denied your request. The Plan says this service is included in the global surgical package. The Plan must follow Medicare rules. Medicare rules say that if the Field 16 of MFSDB entry is 010, A/B MACs (B) do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure.We looked at the file and Medicare rules. The record shows that procedure code 49440was billed on October 30, 2019. CPT code 49440 has an entry of 10 in Field 16 of the MFSDB. The service at issue was performed within the 10-day postoperative period and was not billed with a modifier to indicate it was an unrelated service. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care have not been met.Therefore, we decided that the Plan does not have to pay for subsequent hospital care (99231) provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (CPT 99140) provided to the enrollee on
January 26, 2020.
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 request for additional payment for the emergency nature of the operation is not a covered
benefit.
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 99140 is "Anesthesia complicated by emergency
conditions."
We asked our coding 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 coding reviewer found the medical
records provided do not include documentation that qualifies CPT 99140 for payment consideration. Payment
for CPT 99140 is included in Procedure 01500 as 99140 has a status indicator that is not recognized by OPPS
(Outpatient Prospective Payment System).
We looked at this coder'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 anesthesia services (CPT 99140) provided to the enrollee on January 26, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
December 3, 2019 to December 29, 2019.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied
your request. The Plan says a corrected claim is needed to process these services.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim
was submitted with an incorrect Type of Bill code, 0323. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from December 3, 2019 to December 29, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forbehavioral health services provided on April 7, 2020 byan out of network (OON) provider.You asked the Plan to pay forbehavioral health services. You say that you would like this claim reprocessed and approved for payment.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 forbehavioral health services provided on April 7, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on March 17, 2020.You asked the Plan to waive the copayment for the arthrocentesis. You say that you should only be billed a specialist office visit. You say the provider practices in a hospital setting and you are being charged more. The Plan denied your request. The Plan says the original claim has been reprocessed and 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 $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $150 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 the arthrocentesis provided on March 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac computed tomographic angiography.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show any symptoms.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found in this circumstance, guidelines for the management of cardiac risk and hyperlipidemia do not recommend the routine use of coronary CT scanning with calcium scoring. Cardiac outcome has not been shown to be improved with coronary CT scanning incremental to that which can be achieved using usual clinical risk profiles in conjunction with standard lipid levels. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac computed tomographic angiography.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve10 additional physical therapy (PT) visits.You asked the Plan to pre-approve10 additional PT visits. You say that the 10 additional PT visits are medically necessary.The Plan denied your request. The Plan says that the 10 additional PT visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 10 additional PT visits. Our reviewer says that the 10 additional PT visits are medically necessary. Our physician reviewer found the enrollee underwent a right total knee replacement on 10/17/19. The Initial PT evaluation occurred on 12/11/19. PT 3 times per week was advised for decreased range of motion and strength. She was approved for a total of 30 PT visits from January 1, 2020 to December 31, 2020. On 2/19/20, it is documented that the enrollee was making slow progress. The PT program was to continue 2 times per week at that time. The enrollee was approved for 30 PT visits from 1/1/20 through 12/31/20. The case file contains documentation of PT evaluation on 5/18/20. At that time, the number of PT treatments to date was noted to be 30. The enrollee's range of motion had regressed secondary to no PT visits related to the COVID-19 pandemic. The documentation supports that the unique skills of a professional therapist are required to safely and effectively provide treatment. The additional 10 PT visits are 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 10 additional PT visits have been met.Therefore, we decided that the Plan has to pre-approve10 additional physical therapy (PT) visits.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance transport provided on September 24, 2019.You asked the Plan to pay forthe ambulance transporttodialysis. You say that the transport was medically necessary.The Plan denied your request. The Plan says the enrollee could have beentransported by another type of vehicle.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport todialysis. Our reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was transported betweena skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why alternate modes of transport were not considered. Withoutthe support of the documentation, Medicare criteria were not met. The denial is upheld. 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 ambulance transport todialysis have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance transport provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Spinal cord stimulator.
You asked the Plan to pre-approve a Spinal cord stimulator. You say that the requested Spinal cord stimulator
is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested Spinal cord stimulator.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Spinal cord stimulator. Our reviewer
says that the enrollee does not meet criteria for the requested Spinal cord stimulator. Our physician reviewer
found this enrollee has chronic low back pain without radiation. He had radiofrequency ablation (RFA) of both
lumbar and thoracic facets as well as SI joint lateral branch RFA. His current pain medication is Motrin only.
He has a very brief psychological clearance note. He had not had prior spine surgery, does not have any
sympathetic nerve dysfunction, ischemic peripheral vascular disease or any other evidence based indication for
a Spinal Cord Stimulator. The enrollee has not had other conservative therapy documented.
The enrollee does not have an evidence based indication for this procedure. The enrollee has not had an
adequate trial of conservative therapy. The requested procedure is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Spinal cord stimulator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 1, 2020.You asked the Plan to waive the copayment for the colonoscopy. You say that you had a screening colonoscopy and assumed it would be a free procedure. You say you could not consent to the removal of the polyps.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 $200 copayment per visit, per provider, per day for surgery performed in an in-network ambulatory surgical center. You have been asked to pay a $200 copayment for the colonoscopy. the colonoscopy falls within the per visit, per provider, per day for surgery performed in an in-network ambulatory surgical center benefit category. The medical record shows you signed the Consent to Operation, Anesthesia, and Other Medical Procedures form which specifies that a colonoscopy with biopsies and/or possible removal of polyps may be performed. 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 the colonoscopy provided on February 1, 2020.