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

We decided that the Plan does not have to pay for emergency medicine services (CPT 27230) provided to the enrollee on October 31, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 27230-54 (1 unit) 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 code 27230 is "closed treatment of a femoral fracture, proximal end, neck; without manipulation."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 coded correctly. Our coding reviewer found the medical records provided does not include documentation of a Closed treatment of femoral fracture, proximal end, neck; without manipulation performed on October 31, 2019, therefore this service cannot be validated.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 emergency medicine services (CPT 27230) provided to the enrollee on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 1 power wheelchair for the enrollee.You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary, and a group two power chair if requested could be approved. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this request 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 the wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a group 1 power wheelchair 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 September 27,
2019 to October 1, 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 the enrollee's
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
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 September 27, 2019 to October 1,
2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra injections (J0517).You asked the Plan to pre-approve the injections. You say that the enrollee has been diagnosed with severe persistent asthma.The Plan denied your request. The Plan says that your request is not eligible for coverage under the enrollee's medical benefit as the medication will not be supplied by your office.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to you as the physician and will not be included in your bill to the enrollee, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approve Fasenra injections (J0517).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from October
24, 2019 to December 22, 2019 by the appealing provider.
You asked the Plan to pay for SNF care. You say that the services were provided and payment should be
rendered. The Plan denied your request. The Plan says the appropriate home health data was not included on
the claim submitted. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that home health episode payments must be based
upon the site at which the beneficiary is served.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of SNF care have not been met. Specifically, both value code 61 and value code 85 must be reported.
The claim did include the value code 61 but did not include value code 85. Therefore, we decided that the Plan
does not have to pay for skilled nursing facility (SNF) care provided from October 24, 2019 to December 22,
2019 by the appealing provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinic visit (G0463) provided on January 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON clinic visit. You say that you were not informed this provider was out-of-network. The Plan denied your request. The Plan says this service was not authorized.
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 clinic visit (G0463) provided on January 29, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on December 23, 2019.You asked the Plan to waive the copayment for the office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an office visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $10 copayment for Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rule. The file shows that you received an office visit on December 23, 2019. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the Physician/Practitioner services 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 office visit (99214) provided on December 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided November 8 to November 12, 2019.
You asked the Plan to pay for the emergency room services. You say that the services were medically necessary and properly billed. The Plan denied your request. The Plan says the emergency room services should have been billed separately.
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 the services are not supported in the medical record. Specifically, the Emergency Room services were outpatient services and cannot be billed on an inpatient claim. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services provided November 8 to November 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of the services. You say that you had fallen and you needed assistance getting up because you are elderly. You stated that the responders only spent twenty minutes with you.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 13, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 the medical services provided to the enrollee by an out-of-network provider on January 11, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for chest exploration (39010) provided  on September 17, 2019.You asked the Plan to pay for the chest exploration. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest exploration have not been met. Specifically, the provider who rendered the column II procedure is separate and has a different NPI than the provider who rendered the column I procedure.Therefore, we decided that the Plan has to pay for chest exploration (39010) provided  on September 17, 2019.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 waive the copayment for the ambulance transport provided on December 11, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that this could have been avoided with proper precautions. You say that you shouldn't be responsible for the bill.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ground travel. Cost sharing applies to each one-way trip.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 ambulance transport provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on April 12, 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 the claim was billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct POS code.We looked at the file and Medicare rules. The file shows that code 99326 (domiciliary or rest home visit) was billed with POS code 72 for a rural health clinic. This POS code is not appropriate for this procedure code.Therefore, we decided that the Plan does not have to pay for the services rendered on April 12, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oxygen concentrator purchased on December
26, 2019 from an out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the network supplier did not carry the
quantity of oxygen you needed so you went online and ordered the equipment. The Plan denied your request.
The Plan says you did not request 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. Medicare rules say that only rented oxygen equipment is eligible
for coverage.
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. Purchased oxygen equipment is statutorily non-covered by Medicare. 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 reimburse you for the oxygen concentrator purchased on December 26, 2019 from an out of
network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve3 additional home physical therapy (PT) visits (G0151).You asked the Plan to pre-approve3 additional home PT visits. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 3 additional home PT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the provided medical documentation the records do not show that further skilled therapy services beyond the one approved by the Plan are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Continued utilization of the home exercise program is indicated until a more definitive treatment is provided (such as surgery if indicated).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3 additional home PT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve3 additional home physical therapy (PT) visits (G0151).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hernia repair provided on December 4, 2019.
You asked the Plan to waive the copayment for the hernia repair. You say that the explanations of benefits states you do not have to pay this item. You say that this should be paid. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for Medicare-covered outpatient surgery at an in-network outpatient hospital. You have been asked to pay a $300 copayment for the hernia repair. The hernia repair 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 hernia repair provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the medication and specialist services provided from July 31, 2019 to November 6, 2019.
You asked the Plan to waive the cost share for the medication and specialist services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received medication and specialist services on the dates of service at issue in this appeal. The Plan says the correct cost share has applied per your contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and a $35 copayment for services obtained by a specialist. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received medication on August 14, 2019. You have been asked to pay a 20% coinsurance for the medication, totaling $79.22. This medication falls within the Medicare Part B prescription drugs benefit category. The file shows you received services provided by a specialist on July 31, 2019, August 14, 2019, August 28, 2019, September 25, 2019, October 9, 2019, and November 6, 2019. You have been asked to pay a $35 copayment for each specialist visit. The specialist visits fall within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the medication and specialist services provided from July 31, 2019 to November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is still being studied in clinical trials for efficacy in the treatment of knee pain due to
osteoarthritis or in the setting of replacing or significantly deferring total knee arthroplasty.
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 an experimental and investigational procedure that is the subject of on-going clinical
trials. Therefore, the requested procedure is deemed 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 Plan does not
have to pre-approve genicular nerve radiofrequency ablation for the enrollee.