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

We decided that the Plan does not have to pre-approverepeat radiofrequency ablation (RFA) procedure.You asked the Plan to pre-approveradiofrequency ablation(RFA). You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee did not have sustained pain relief of at least 50% for at least 6 months following the previous procedure.The Plan follows Medicare rules. Medicare rules say that repeat denervation procedures involving the same joint will only be considered medically necessary if the prior procedure provided at least 50% pain relief and improvement in activities of daily living that are documented for at least 6 months.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 topre-approve radiofrequency ablation (RFA). Our reviewer says that the enrollee does not meet the Medicare criteria for the requested procedure. Our physician reviewer found the enrollee underwent a prior RFA on August 28, 2019 and achieved 100% pain relief. At a subsequent visit her pain relief decreased to 50% but fell to 30% before 6 months. Therefore, the request does not meet the Medicare criteria of pain relief lasting at least 6 months and is not 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 radiofrequency ablation (RFA) have not been met.Therefore, we decided that the Plan does not have to pre-approverepeat radiofrequency ablation (RFA) procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on February 6, 2020.You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you are unable to pay such a high copayment for this procedure.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 $400 copayment for freestanding ambulatory surgical center. You have been asked to pay a $400 copayment for the upper GI endoscopy. The upper GI endoscopy 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 upper GI endoscopy provided on February 6, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvean MRI of the spinal canal (72156).You asked the Plan to pre-approvethe MRI. You say that you would like reconsideration because the MRI is medically necessary.The Plan denied your request. The Plan says that the most recent information provided with the appeal does not describe these result of the recent electromyography and nerve conduction study.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that there is a concern for cervical myelopathy. Our physician reviewer found the requested MRI is medically reasonable and 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 the MRI have been met.Therefore, we decided that the Plan has to pre-approvean MRI of the spinal canal (72156).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 decideto open 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 an urgent care global fee provided on November 10, 2019.
You asked the Plan to pay for urgent care fee. You say that you are eligible to have urgent care coverage. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this code is not payable by Medicare. The Plan also says that the services you received are covered, but the provider must bill the claim with a valid code that Medicare covers.
The Plan must follow Medicare rules. Medicare rules say that procedure code S9083 is not valid for Medicare purposes and is not covered. We looked at the file and Medicare rules. The procedure code billed by the provider is not valid for Medicare purposes, the provider should resubmit a bill using a valid code. Based on this information, we decided that Medicare rules for coverage of urgent care fee have not been met. Therefore, we decided that the Plan does not have to pay for an urgent care global fee provided on November 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid 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 the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 the drug testing services provided on January 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 2, 2019.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service is not covered as indicated by the modifier submitted.
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 provider submitted their claim for payment with a GY modifier that indicates that the services provided were non-covered by Medicare. The ambulance provider has submitted a claim that cannot be paid based on Medicare billing guidelines. Because the provider is out-of-network, the plan cannot over-ride the claim. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT codes 81120, 81121, and 81201 provided on November 11, 2019.You asked the Plan to pay forCPT codes 81120, 81121, and 81201. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. There is limited coverage for CPT codes81120 and 81121 and ICD-10 code C34.90 is not acovered diagnosis code for theseservices. Furthermore, Medicare saysgenetic testing procedures submitted under CPT code 81201 will be denied automatically as not medically necessary.Therefore, we decided that the Plan does not have to pay forCPT codes 81120, 81121, and 81201 provided on November 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out of network provider.You asked the Plan to pay for the medical services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the services were not urgent or emergent, and not arranged by the Plan.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 service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay for the medical services provided on January 22, 2020 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 15, 2020.You asked the Plan to waive the copayment for ambulance services. You say that you have spent a lot of time arranging transportation and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $125 copayment for ambulance services. The enrollee has been asked to pay $10, which is less than the $125 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the chest.You asked the Plan to pre-approveCT scan. You say that the enrollee is overdue for follow-up of a known lung nodule.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show that follow-up for the enrollee's condition is needed.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 wascorrect in denying the request to pre-approve CT scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scan. Our physician reviewer found according to the Fleischman criteria, there is no further follow-up required as the enrollee is a non-smoker and the enrollee's lung nodule is less than 6 millimeters.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Computed Tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit for wound care provided on January 29, 2020.
You asked the Plan to pay for the hospital outpatient clinic visit for wound care. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 a hospital outpatient clinic visit for wound care provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon December 10, 2019.You asked thePlan to pay for the physician's services.The Plan denied your request. The Plan says services from non-participating providers are not covered under your Plan unless they are authorized by the Plan before the services are provided.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 physician's 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 physician's services provided on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for aggressive rehab to regain
maximum function. The Plan denied your request. The Plan says the enrollee does not need to be seen by a
rehab doctor 3 days a week, or an intensive team for 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 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 physician reviewer found
that the enrollee is on a mechanical soft diabetic diet and has some neurologic return on the right side. He is at
maximal assist for bed mobility and for sit-to-stand. He is currently unable to fully ambulate. He is at moderate
to max assist for activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. He
may benefit from additional multiple therapies, however the enrollee's functional level does not require or
indicate that this therapy must be in an IRF with an intensive level program.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveradiofrequency ablation of the SI joint for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered experimental and investigational for the treatment of sacroiliac joint mediated pain.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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental and investigational, because of the wide variation in efficacy reported in the peer-reviewed literature. Therefore, the request is considered 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveradiofrequency ablation of the SI joint for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 3, 2019 to December 26, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says no daily skilled nurse or therapist was needed.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 3, 2019 to December 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair replacement of mirrors, cover lid, and shroud assembly.
You asked the Plan to pre-approve power wheelchair mirrors, cover lid, and shroud assembly. You say that the items are used in the home and serve a medical need. The Plan denied your request. The Plan says while a power wheelchair accessory may also be useful outside of the home the main use must meet an in-home medical need.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The items at issue in this appeal are for mobility outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve power wheelchair replacement of mirrors, cover lid, and shroud assembly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on October 21, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment. 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 $25 copayment for each visit for Medicare-covered specialist services received in a network provider's office. You have been asked to pay a $25 copayment for the specialist office visit. The specialist office visit falls 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 copayment for the specialist office visit provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the CPAP supplies purchased on January 15, 2020.
You asked the Plan to reimburse you for the CPAP supplies. You say that you were trying to save the Plan money and did not realize there was such a thing as in-network or out-of-network providers. The Plan denied your request. The Plan says a provider must be eligible to participate in Medicare to receive payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the CPAP supplies purchased on January 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy rendered on February 20, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that return trips to the operating room for a related procedure during a postoperative period must be billed with modifier -78.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 63047 with modifier -78 to signal a return trip during a postoperative period; however, the file shows that the postoperative period for the initial procedure had ended at the time the services at issue were performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe laminectomy rendered on February 20, 2020.