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

We decided that the Plan does not have to pre-approve knee arthrotomy 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 not medically necessary.
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 the enrollee presented status post a slip and fall on 1/3/19 with left ankle pain and swelling. X-rays were obtained and showed an oblique mildly displaced fracture through the distal fibula, and horizontally mildly displaced fracture at the base of the medial malleolus. He has been approved for open reduction and internal fixation of the bimalleolar ankle fracture (CPT code 27814) on an outpatient basis. The medical necessity of inpatient admission is not documented in the submitted medical records, as it was noted that he would be an observation stay if well tolerated. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of pre-authorization of an inpatient admission as an exception to Medicare guidelines. Therefore, the request for inpatient surgery would not be considered 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthrotomy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on July 15, 2019.
You asked the Plan to pay for the compression stockings. You say that you have varicose veins and require the stockings for treatment. The Plan denied your request. The Plan says the gradient compression stockings are noncovered as they are non-reusable supply items.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6549 that were issued on July 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forIntelliScore laboratory testing (0005U) provided on July 10, 2019.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered.The Plan follows Medicare rules. Medicare rules say that one biomarker test is covered prior to initial biopsywhen the above criteria are 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 pay for the testing. Our reviewer says that the requested IntelliScore laboratory testing was not medically reasonable and necessary. Our physician reviewer found that the medical records provided do not support coverage of IntelliScore laboratory testing. No specific contraindications to prostate biopsy were provided. The PSA level and DRE were not provided.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 testing have not been met.Therefore, we decided that the Plan does not have to pay forIntelliScore laboratory testing (0005U) provided on July 10, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH). You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the acute care hospital is able to provide all of the services the patient requires. Based on the provided medical records the patient is receiving necessary services and is at an appropriate level of care in the acute care hospital. The enrollee is getting the currently needed services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. Overall the enrollee appears to be very ill despite intensive treatment in the acute hospital -it is doubtful the long term acute care hospital (LTACH) would have anything additional to offer for this enrollee.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe services rendered to you on July 29, 2019 and August 7, 2019.You asked the Plan to waive the copayments forthese services. You say that the services were not rendered.The Plan denied your request. The Plan says the copayments were 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 $50 copayment for specialty physician services and a $50 copayment for outpatient diagnostic tests from a specialty physician.Review of the file shows that you received office visit services on July 29, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the specialty physician services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you received evaluation services for an implantable heart recorder system on August 7, 2019. You have been asked to pay a $50 copayment for these services. These services fall within the outpatient diagnostic tests from a specialty physician benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.The total amount you have been asked to pay for these services is $100. 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 copayments forthe services rendered to you on July 29, 2019 and August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on March 25, 2019.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 physician services provided on March 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services (73080TC) provided
September 16, 2019 by the provider.
You asked the Plan to waive the copayment for the radiology services. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 $60
copayment for X-rays and Ultrasounds.
You have been asked to pay a $60 copayment for radiology services. The radiology services fall within the Xrays
and Ultrasounds 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 radiology
services (73080TC) provided September 16, 2019 by the provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit, and eye exam with photos provided on March 29, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that you had an emergency visit to the eye doctor. You say that you had a sudden flood of floaters in your left eye. You also say that you did not have time to wait for an appointment with your primary care physician, or to wait for a referral. The Plan denied your request. The Plan says that authorization was not obtained before the services were provided to the enrollee.
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. SCAN follows these rules. You received the services from the provider. He is a contract provider. The file does not show that SCAN provided notice that the physician services would not be covered. Under Medicare rules, this means the physician services is considered approved by SCAN. Therefore, we decided that the Plan has to pay for the office visit, and eye exam with photos provided on March 29, 2019 by the out of network provider.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveankle foot orthoses identified with codes L1940, L2330, L2275, and L2820.You asked the Plan to pre-approvethe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says they did not receive any clinical information explaining why these custom braces are necessary. Despite multiple attempts, we were unable to get the clinical information.The Plan must follow Medicare rules. Medicare rules say that the ankle must have weakness that requires stabilization and the potential to benefit functionally.We looked at the file and Medicare rules. The member does not have a physical deformity of the ankle and foot, nor does he have weakness requiring stabilization for medical reasons. In addition, the physician has not documented a specific reason why the member requires a custom orthosis rather than a prefabricated orthosis. Because of this, the request does not meet the Medicare Local Coverage Determination and remains denied.  
Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met.Therefore, we decided that the Plan does not have to pre-approve ankle foot orthoses identified with codes L1940, L2330, L2275, and L2820
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pay for the definitive drug panel for 22 or more drug classes provided on July 23, 2019.You asked the Planto payforthe definitive drug panel. You say that the provider established their practitioner protocol and ordered it for this patient. This is supported by the medical records for that date.The Plandenied your request. The Plansaysthatthe Practitioner Protocol Panel details received did not contain a patient name. The submitted documentation does not itemize what tests are included in this panel; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating physician. In this case, the document which defines the practitioner's protocol with this lab does not need to have a patient name as the protocol is specific to the provider. This provider ordered his/her defined protocol and this was provided as per the documentation. There is sufficient evidence that the treating provider intended to order the rendered testing.Therefore, we decided that the Planhas to pay forthe definitive drug panel for 22 or more drug classes provided on July 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four testing (95999) provided on October 21, 2018.You asked the Plan to pay for the Train of Four testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Train of Four is considered a bundled procedure and payment for it is included in payment for the already approved neuromonitoringThe Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coder 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 Train of Four testing. Our reviewer says that unlisted CPT code 95999 is not supported. Our reviewer found the record shows that this code was reported for train of four testing. According to CPT rules, train of four testing is included in other neuromonitoring procedures and is not reported separately.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 Train of Four testing have not been met. Therefore, we decided that the Plan does not have to pay for Train of Four testing (95999) provided on October 21, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 28, 2018.
You asked the Plan to pay for the orthosis. 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. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 28, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 17, 2019.You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 physician services provided on July 17, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the definitive drug testing panel of 22 or more drug classes provided on July 19, 2019.
You asked the Plan to pay for the definitive drug panel. You say that this was ordered by the treating provider and should be paid. The Plan denied your request. The Plan says that the order does not indicate what drugs would be tested in the panel selected.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordered by the treating provider. In this case, we find that the test order form does indeed define the testing being requested in the Comprehensive Pain Mgmt Profile. The order form shows various groups of analytes, Group 2000-2008. There are three panels, 2100 which indicates all groups aside from 2002, 2006, and 2008, 2300 which is only opiates, and 2100 which is listed as all, meaning all groups 2000-2008. This is sufficient to support that the provider intended a 22 or more drug panel to be performed. Therefore, we decided that the Plan has to pay for the definitive drug testing panel of 22 or more drug classes provided on July 19, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genicular nerve blocks (64450x3) provided on May 30, 2019.You asked the Plan to pay for the genicular nerve blocks. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the units billed.The Plan must follow Medicare rules. Medicare rules say that providersmust report services correctly. Providers must report services with the appropriate CPT code.We asked our coder 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 genicular nerve blocks. Our reviewer says that 3 units are not supported. Our reviewer found the record shows that a genicular nerve block was performed. According to CPT rules, 64450 is reported once for this procedure, regardless of the number of injections needed to perform the block.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 genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pay for genicular nerve blocks (64450x3) provided on May 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance services (A0429) and ground
mileage (A0425) provided by the ambulance service on April 11, 2019.
You asked the Plan to pay for the ambulance services. You say that you spoke with a plan representative who
said that you should be covered and that you may owe a deductible. The Plan denied your request. The Plan
says the provider has been informed that this service was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
The plan says that several attempts was made to get a correct claim from the provider. The plan is not able to
process the claim how it is currently billed. Specifically, payment is not allowed for condition code 21 when
submitted with a type of bill that has anything other than a zero in the 3rd position. A corrected claim needs to
be submitted by the provider with an appropriate condition code for claim reconsideration. Based on this
information, we decided that Medicare rules for coverage of the ambulance services have not been met.
Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance services (A0429)
and ground mileage (A0425) provided by the ambulance service on April 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the excision of a malignant lesion provided on August 14, 2019 by the  out of network provider.

You asked the Plan to pay for the surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.

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 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 excision of a malignant lesion provided on August 14, 2019 by the  out of network provider.