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

We decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 10, 2020.
You asked the Plan to pay for the orthosis. You say that you trust that the verification provided will be deemed sufficient to allow verification of the claims at issue and to remit payment for the pending claims as soon as possible. The Plan denied your request. The Plan says services not documented in the enrollee's medical records and the supporting documentation does not match the information sent on the claim.
Medicare has specific coverage criteria for each type of orthosis. Based on the records provided, the enrollee did not meet the criteria needed for the orthosis provided. the enrollee did not receive a video or telephonic visit by the ordering physician in order to warrant the codes billed. There are no claims on file with the ordering physician listed in the enrollee's claims history from 2019-present. There were no serviced found for the enrollee billed on the service date. Based on this information, we decided that the Plan does not have to pay for the knee orthosis (L1833) and suspension sleeve (L2397) provided October 10, 2020.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found in this case, the enrollee was admitted to acute care facility for stroke and had subsequent respiratory failure. The enrollee continues to receive acute care services for which coverage has not been denied. The enrollee does not require acute care services which he is unable to obtain at the current facility but which the LTACH could provide. The elements of the coverage determination are not satisfied. The requested service is not 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the specialist office visit, the x-ray, and the Part B drug provided on December 8, 2020.
You asked the Plan to reduce the cost share for the specialist office visit, the x-ray, and the Part B drug. You say that you have had this injection before, and it did not cost as much. The Plan denied your request. The Plan says you have been asked to pay 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 $30 copayment for each specialist visit or telehealth service for Medicare-covered services, a $20 copayment each Medicare-covered x-ray, and 20% of the cost for Medicare-covered Part B drugs (including chemotherapy drugs).
You have been asked to pay a total of $166.48 for the specialist office visit, the x-ray, and the Part B drug. The specialist office visit falls within the "Physician/Practitioner services, included doctor's office visits" benefit category. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment/
Coinsurance
Member Liability
December 8, 2020
Specialist office visit
$71.06
$30
$30
December 8, 2020
X-ray
$35.48
$20
$20
December 8, 2020
Part B injection
$748.10
20%
$116.48
Total
$166.48
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 reduce the cost share for the specialist office visit, the x-ray, and the Part B drug provided on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the cervical traction equipment (E0849) rendered by an out of network (OON) provider on January 18, 2021.

You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this item was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to issue reimbursement for the cervical traction equipment (E0849) rendered by an out of network (OON) provider on January 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CTA, heart, coronary arteries and bypass grafts (when
present), with contrast material, including 3D image postprocessing (CPT code 75574), for the enrollee.

You asked the Plan to pre-approve the CTA scan. You say that the service is necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met.

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 CTA scan. Our physician reviewer
found the enrollee does not meet any of the stated criteria for multidetector computed tomography (MDCT)
angiography of the chest for cardiac assessment. Additionally, a review of the provider's progress note from
April 19, 2021, does not mention a request/order for this study (CPT Code 75574). The review indicates that
the medical records provided did not meet the requirements listed in the LCD for Medicare coverage.

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 CTA scan have not been met. Therefore, we decided that the Plan does not
have to pre-approve CTA, heart, coronary arteries and bypass grafts (when present), with contrast material,
including 3D image postprocessing (CPT code 75574), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the skilled nursing facility (SNF) services you received from December 18, 2020, to December 31, 2020.
You asked the Plan to adjust the cost share. You say that the services should be processed as in-network. The Plan denied your request. The Plan says you are responsible for the out-of-network cost share.
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% coinsurance per day for days 1-100 for out-of-network skilled nursing facility care. Review of the file shows that you were provided SNF services from December 18, 2020, to December 31, 2020. You have been asked to pay a 40% coinsurance for the services, totaling $124.79. The services fall out-of-network 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 adjust the cost share for the skilled nursing facility (SNF) services you received from December 18, 2020, to December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. 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 physician services provided on January 4, 2021 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care and subsequent hospital care provided from August 29, 2020, to August 31, 2020.
You asked the Plan to pay for the initial hospital care and subsequent hospital care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 27, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care and subsequent hospital care provided from August 29, 2020, to August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Pure Wick incontinence device.
You asked the Plan to pre-approve the requested services. You say that the enrollee is at high risk for falls. The Plan denied your request. The Plan says the item is not covered for the enrollee's condition.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve the Pure Wick incontinence device.
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 IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says rules for IRF care have 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 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 patient was admitted to an acute care hospital for altered mental status and constipation. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does 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 this patient 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: 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 minimal therapy at a lower level of care will delay his return to his prior level of functioning. The Plan denied your request. The Plan says the records do not indicate the enrollee needs or can tolerate an intensive therapy program.

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 physician reviewer found that the enrollee was admitted to the acute hospital for congestive heart failure. His medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services.

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: Lab
Decision: Favorable

We decided that the Plan has to pay for Guardant360 testing provided on February 24, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and should be
paid. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because
this testing was not ordered by the ordering physician.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
This testing was ordered by an in-network provider. The file does not show that the plan provided notice that
genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved
by the plan. Therefore, we decided that the Plan has to pay for Guardant360 testing provided on February 24,
2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on December 7, 2020.
You asked the Plan to pay for the eye refraction. You say that you know you already had a routine refraction earlier this year, but this one was done for an evaluation of a cataract. The Plan denied your request. The Plan says only routine refractions can be covered, and there is a limit to one per year. The Plan already paid for an eye refraction in March of 2020. Therefore, this service cannot be covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan can cover one routine eye exam and refraction per year. We looked at the file and the Plan's rules. The Plan already paid for an eye refraction for you in 2020 as part of a routine vision exam. This service is limited to one per year. In addition, eye refractions for a medical purpose are not a covered service under Medicare or the supplemental benefit. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met.
Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on December 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a tens unit and lead (A4595, E0745) a wrist-hand orthosis
(L3916), an ankle-foot orthosis (L1971), and foot stabilizer (L3170) provided to the enrollee on November 11,
2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical
record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the
type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed
supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to
pay for a tens unit and lead (A4595, E0745) a wrist-hand orthosis (L3916), an ankle-foot orthosis (L1971), and
foot stabilizer (L3170) provided to the enrollee on November 11, 2020.
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 you need to get therapy underway. The Plan denied your request. The Plan says you do not need an intensive therapy program with multiple visits from a rehab doctor.

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 physician reviewer found that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical problems are stable. There are no complex nursing needs. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

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: 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 stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for an abdominal abscess. Medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does 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 this enrollee 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 IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (95941) provided on June 2, 2020.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 95941 has a status indicator of I and is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95941 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 95941 has a status indicator of I. This means that CPT code 95941 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (95941) provided on June 2, 2020.