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

We decided that the Plan does not have to pay forthe massage therapy (97124) provided on March 10, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe massage therapy. You say that you purchased a supplemental package which covers out of network services for chiropractic treatments at 50%. Prior to the COVID 19 shut down your chiropractic treatments in February were reimbursed.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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.The rules say that the only chiropractic service Medicare covers is manual manipulation
of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. We foundno exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe massage therapy (97124) provided on March 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on July 15, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe place of service on the CMS-1500form line 24B must reflect the location of the patient when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that CPT code 83036 and HCPCS P9604 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory(POS 81), while the records reflect of place of service of a doctor's office (POS 11) Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynthroid for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plandenied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveSynthroid for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from November 24, 2019 to January 21, 2020.
You asked the Plan to pay forhome health services. You say that you would like reconsideration because you are an in-network provider and have 180 days to submit a final claim.The Plan denied your request. The Plan says the allowable final claim was not received before 120 days after the start date of the episode or 60 days after the calculated end date of the episode or periodThe Plan must follow Medicare rules. The rules say that if the claim is not received 60 days after the calculated end date of the episode (day 120) or period (day 90) or 60 days after the paid date of the RAP (whichever is greater), the RAP payment will be canceled automatically by Medicare claims processing systems.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, [ADJUDICATOR -ENTER INCOMPLETE, MISSING, OR INVALID DATA ELEMENTS]. Specifically, the record indicates that the final claim was not submitted within 60 days after the calculated end date of the episode (day 120) or period (day 90) or 60 days after the paid date of the RAP.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from November 24, 2019 to January 21, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran intermittent limb compression device.You asked the Plan to pay foran intermittent limb compression device. 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 foran intermittent limb compression device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9338) provided on July 21, 2020.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT code S9338 has a status indicator of I which 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 S9338 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9338 has a status indicator of I. this means that CPT code S9338 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9338) provided on July 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe dental services.You asked the Plan to pre-approvethe dental services. You say that these are not dental services.The Plan denied your request. The Plan says the services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe dental services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay forx-ray services (CPT 71046) provided to the enrollee on June 24, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCPT 71046 was performed post-thoracentesis, and was not performed as a separate service from the included post-procedure x-ray.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 CPT code 71046 has a bundled relationship with CPT code 32555 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 Plandoes not haveto pay forx-ray services (CPT 71046) provided to the enrollee on June 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on August 19, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 haveto pay forlab work provided on August 19, 2020 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring
system.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary, as you have to poke
your fingers again and again. 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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you are not on insulin. You do not require insulin injections. This monitor cannot be approved.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Freestyle Libre continuous glucose monitoring system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99497) provided on April 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.
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 99497 is "Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate". We find that CPT code 99497 is not supported in the medical record. Specifically, the records do not show the time spent providing these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 99497) provided on April 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on May 20, 2020. You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says this claim was denied because "new patient" qualifications were not met, paymentfor this type of service was already made for services rendered to the same enrollee by the same enrollee on March 3, 2020. Chapter 12, Section 30.6.7 of the  Medicare Claims  Processing Manual states "Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within  the previous 3 years." Services were previouslyrendered by the same provider, therefore, the claim denied correctly as this is not a new patient evaluation.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 claim submitted has an error regarding the new patient code billed. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on May 20, 2020 by
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided to the enrollee on May 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says there was a DRG procedure code error.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that the denied codes are not supported in the medical record. Specifically, this was billed as a non-covered procedure per the IPPS MCE. 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 inpatient services provided to the enrollee on May 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.The Plan must follow Medicare rules. Therules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying 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 surgical treatment of a leg fracture after a fall from height. Medical problems are stable. There are no identified problems that need inpatient medical management. 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. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will beable 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services and travel expenses provided from November 4, 2019, to November 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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. In this case, the CPT Code Manual definition of code P9604 is "Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge". We find that CPT code P9604 is not supported in the medical record. Specifically, the documentation does not
show the miles traveled or patients seen during travel. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare rules also say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in a skilled nursing facility setting, which would be indicated by POS code 31. This means that the claim was billed with the incorrect POS code. Therefore, we decided that the Plan does not have to pay for the lab services and travel expenses provided from November 4, 2019, to November 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says by using your previous wheelchair in the rain, this would be considered abuse or neglect, and a replacement would not be covered.
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 home assessment is conflicting that you would be able to safely operate the power wheelchair for participation in MRADLs in the home as the 10/5/20 home assessment states that there is not sufficient space to turn with a power wheelchair in the home. 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 replacement power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services coded 81227, 81230, 81231, 81328, 81401 and 81479 provided on November 20, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 codes 81227, 81230, 81231, 81328, 81401 and 81479 are not supported in the medical record. Specifically, laboratory results have not been submitted for the billed date of service. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services coded 81227, 81230, 81231, 81328, 81401 and 81479 provided on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the medical services provided on December 19, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for a knee scooter. You say that you attempted to get the supplies twelve times from
different in-network providers. The only one that could give you the supplies would not the knee scooter there
in time for your procedure. The Plan denied your request. The Plan didn't render a decision within
the allotted timeframe; therefore had to submit the case as an auto-forward. The Plan additionally did not only
pre-approve the service, but attempted to pay for the claim, but did not pay for the services correctly and asked
the enrollee to refile, which the enrollee did.
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, but the enrollee could not receive
services from an in network provider in timely fashion. The Plan did not have network providers available who
could provide the items/services at issue in this appeal. The Plan pre-approved the item/service at issue. We
found the services were urgently needed care when the network was not available. Therefore, we decided that
the Plan has to pay for the medical services provided on December 19, 2019 by an out of network (OON)
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.