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

We decided that the Plan does not have to pay for the laboratory services provided on November 24, 2020.
You asked the Plan to pay for the laboratory services. You say that the test meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management of the enrollee's advanced cancer. You say that the decision should be reversed with a favorable resolution. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the acupuncture (CPT code(s): 97811 and 97810) provided from November 30, 2020, through December 16, 2020.
You asked the Plan to reimburse for the acupuncture. You say that you paid upfront for six (6) acupuncture visits from November 30, 2020, to December 16, 2020. You state you believed you would be reimbursed because one previous claim was submitted to the Plan and they reimbursed you. The Plan denied your request.
The Plan says their records reflect that you were reimbursed for date of service November 25, 2020, and it was confirmed that you were reimbursed in error.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Your EOC clearly states that acupuncture is covered for relief of pain or in the place of anesthesia for a surgical or dental procedure and must be provided by a physician licensed to perform the service. There are no other claims from you or provider showing that the acupuncture service was performed for a surgical or dental procedure. Therefore, we decided that the Plan does not have to reimburse for the acupuncture (CPT code(s): 97811 and 97810) provided from November 30, 2020, through December 16, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) services.

You asked the Plan to pre-approve the PET/CT scan. You say that the enrollee has already been diagnosed with prostate cancer and wants to confirm whether or not the cancer has spread. The Plan denied your request. The Plan says a PET scan is not supported for the first staging of prostate cancer.

The Plan must follow Medicare rules. Medicare rules say that PET 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 PET/CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found PET is reserved if the results of conventional imaging are negative, suspicious, or equivocal. This enrollee has not had CT scan or bone scans. The enrollee should undergo standard staging imaging with a CT scan and bone scan. 

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 PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) services.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member needs rehabilitation. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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 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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for right leg cellulitis. The enrollee's 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Tetanus/Diptheria immunization you
received on October 8, 2020.

You asked the Plan to waive the coinsurance for the Tetanus/Diptheria immunization. You say that this was a
Coronavirus vaccine and you should not have to pay anything. The Plan denied your request. The Plan says
you were charged this coinsurance 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 20%
coinsurance for immunizations except for pneumonia, influenza, and Hepatitis B.

You have been asked to pay 20% coinsurance for the Tetanus/Diptheria immunization. Records show that on
this date, you received a Tetanus/Diptheria vaccine, NOT a Coronavirus vaccine. the Tetanus/Diptheria
immunization falls within the immunizations except for pneumonia, influenza, and Hepatitis B 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 coinsurance for the Tetanus/Diptheria immunization you
received on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and services (CPT code(s): 99214, 17000, 17110) provided to the enrollee on December 16, 2020, by an out-of-network provider.
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 the office visit and services (CPT code(s): 99214, 17000, 17110) provided to the enrollee on December 16, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered on October 30, 2020 to November 10, 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 the claim was not billed with the correct Present on Admission indicator.

The Plan must follow Medicare rules. Medicare rules say that hospitals shall code any conditions the patient has at the time of the order to admit as an inpatient as POA irrespective of whether or not the patient had the condition at the time of being registered as a hospital outpatient.

We looked at the file and Medicare rules. The file shows that the inpatient claim was not billed with the proper POA indicator. 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 inpatient hospital services rendered on October 30, 2020 to November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital for surgical repair of a femur fracture. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ear wax removal (69210) provided on February 1, 2021. 
 
You asked the Plan to pay for ear wax removal. You say that this should be covered. The Plan denied your 
request. The Plan says this is not separately payable. 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, we have confirmed that code 69210 
has a bundled relationship with code 92557 and cannot be paid as billed. This code cannot be paid as a separate 
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided 
that the Plan does not have to pay for ear wax removal (69210) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the arthrocentesis (20610), the 
Orthovisc injection (J3724), and the fluoroscopic guidance for insertion of needle (77002) provided on January 
25, 2021. 
 
You asked the Plan to pay an additional amount for the specialist services and injection. You say that you 
received a bill for $1,673.84. You say that you then received a bill for $568.70 from the same provider. You 
also say that you are on disability and have no means to pay this bill. The Plan denied your request. The Plan 
says there is an 20% coinsurance for Medicare Part B prescription drugs. The Plan says that there is a $25 
copayment for in network specialist visits. visc injection (J3724), and the fluoroscopic guidance for insertion of needle (77002) provided on January 
25, 2021. 
 
You asked the Plan to pay an additional amount for the specialist services and injection. You say that you 
received a bill for $1,673.84. You say that you then received a bill for $568.70 from the same provider. You 
also say that you are on disability and have no means to pay this bill. The Plan denied your request. The Plan 
says there is an 20% coinsurance for Medicare Part B prescription drugs. The Plan says that there is a $25 
copayment for in network specialist visits.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 20% 
coinsurance for Medicare Part B prescription drugs and a $25 copayment for an in network specialist visit.  
 
You have been asked to pay 20% coinsurance for the injection and a $25 copayment for the specialist services. 
The injection falls within the Medicare Part B prescription drug benefit category. The physician services fall 
within 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 pay an additional amount 
for the arthrocentesis (20610), the Orthovisc injection (J3724), and the fluoroscopic guidance for insertion of 
needle (77002) provided on January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leuprolide acetate for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the actual diagnosis of prostate cancer can only be made with a prostate biopsy.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee does not have biopsy confirmation of prostate. There is only an elevated prostate specific antigen (PSA). This drug would not be safe and effective without a biopsy first. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Leuprolide acetate for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 12, 2021, to February 18, 2021 and billed under code S9367.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says this code has a status indicator of "I" which means it is not a valid code for Medicare claims. Medicare uses another code for reporting this service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code reported on the claim is statutorily excluded for Medicare purposes. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from February 12, 2021, to February 18, 2021 and billed under code S9367.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair accessory, power standing feature (E2300) and electronic connection between wheelchair controller and two or more power seating system motors (E2311).
You asked the Plan to pre-approve the power wheelchair accessories. You say that please approve this medically necessary component for the enrollee, so he can use and operate his power wheelchair independently and safely. The Plan denied your request. The Plan says these items are not covered benefits under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked the file, and Medicare rules. Medicare rules say that power standing feature is not covered because it is not primarily medical in nature. If a wheelchair has an electrical connection device coded as E2310 or E2311 and the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. Based on this information, we decided that Medicare rules for coverage of the power wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair accessory, power standing feature (E2300) and electronic connection between wheelchair controller and two or more power seating system motors (E2311).
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 enrollee meets the criteria and would
benefit from the level of care at an LTACH. The Plan denied your request. The Plan says the criteria for an
LTACH are not met, and the enrollee's continued care needs can be provided in another setting.
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 LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where they are currently receiving care. The
requested LTACH services are not medically necessary, reasonable and appropriate for the diagnosis and
condition of the enrollee at this time.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxygen from a new provider for the enrollee.

You asked the Plan to pre-approve the new provider. You say that you are having nothing but issues, as your original rental company was bought out by a new company. The Plan denied your request. The Plan says needs can be met with the current oxygen supplier.

The Plan must follow Medicare rules. Medicare rules say that a new 36-month rental period does not start with a change in supplier. 

If the enrollee were to switch suppliers, the new supplier would not be paid by the plan. The equipment is beyond the 36-month point, but still within the five year (60 month) reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of the new provider have not been met. Therefore, we decided that the Plan does not have to pre-approve oxygen from a new provider for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the speech therapy services received by the enrollee on November 18, 2020.
You asked the Plan to waive the copayment for the speech therapy services. You say that you feel the enrollee's cost share should be waived due to the Coronavirus. The Plan denied your request. The Plan says the claim has been processed correctly per the enrollee's plan benefits.
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 $20 copayment for outpatient rehabilitation services.
The enrollee has been asked to pay a $20 copayment for the speech therapy services. The speech therapy services fall within the outpatient rehabilitation services benefit category. Review of the file does not support that the services received by the enrollee on November 18, 2020 was telemedicine. A telemedicine modifier was not billed with this date of service. 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 the speech therapy services received by the enrollee on November 18, 2020.