Persius/hicric huggingface dataset:
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 requires LTACH care. The Plan denied your request. The Plan says the enrollee can be treated at the current hospital.
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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia and a small bowel obstruction. The enrollee has completed a course of antibiotics and her small bowel obstruction has resolved. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on August 8, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you were told that you would only owe a $125 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for surgery services provided in an ambulatory surgical center and a $150 copayment for surgery services provided in an outpatient hospital facility. You received an EGD at an outpatient hospital facility on August 8, 2019. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for an EGD. An EGD 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 an EGD provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on August 26, 2019.You asked the Plan to pay for the hospital discharge day management. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says another discharge day management code, 99238, for the same date of services has been processed and paid.The Plan must follow Medicare rules. Medicare rules say that only one hospital discharge day management service is payable per patient per hospital stay.We find that CPT code 99239 is not supported in the record. Specifically, the record indicates the another discharge day management code, 99238, has been processed and paid by the Plan. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for more than 30 minutes of hospital discharge day management services (99239) provided on August 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 20, 2019You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this service was mandatory per hospital protocol.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of 
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 15, 2019.
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 noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on March 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 14, 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 procedure code 83721 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 83721 and 80061. Code 83721 is a column II code with a modifier indicator of 1 when billed with column I code 80061. Code 83721 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on July 16, 2019.
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. 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 behavioral health services provided on July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana.You asked the Plan to pre-approve Invokana. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered benefit.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 Invokana.Benefits for Invokana 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: 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 the request for IRF stay is medically necessary and a lesser level of care places the enrollee at significant risk. The Plan denied your request. The Plan says IRF admission is not medically necessary for this enrollee.
The Plan must follow Medicare rules. The rules 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 in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or acute rehab nursing care. While she may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81317, 81404, 81162, 81201,
81295 and 81298 provided on May 6, 2019.
You asked the Plan to pay for the 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 81317, 81404, 81162, 81201, 81295 and 81298 are not supported in the medical
record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the
enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim
history indicates that the specimen was obtained in an office setting place of service 11. 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 for the laboratory services coded 81317, 81404,
81162, 81201, 81295 and 81298 provided on May 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular pathology procedure (81479) provided on August 13, 2019 by the out of network provider.
You asked the Plan to pay for a molecular pathology procedure. You say that the test was medically necessary to the patient and should be paid at 100%. The Plan denied your request. The Plan says the facility is a non-network provider who does not work with the member's health plan. The member was referred by a nurse practitioner who also does not work with the member's plan. The member's primary care physician did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a molecular pathology procedure (81479) provided on August 13, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBrovana (Arformoterol tartrate).You asked the Plan to pre-approveBrovana. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Brovana. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has had a trial of Perforomist (formoterol). The documentation does not support that Perforomist (formoterol) would likely be less effective, and/or would likely haveadverse effects for the enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Brovana have not been met.Therefore, we decided that the Plan does not have to pre-approveBrovana (Arformoterol tartrate).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe moderate sedation services coded 99153 provided on June 14, 2019.You asked the Plan to pay forthe moderate sedation 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.In this case, the CPT Code Manual definition of code 99153 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).We find that CPT code 99153 is not supported in the medical record. Specifically, the documentation submitted and claim form indicate that this procedure was performed in a facility place of 22 (On Campus-Outpatient Hospital). Payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met.Therefore, we decided that the Plan does not have to pay forthe moderate sedation services coded 99153 provided on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on August 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 4, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 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 physician's services provided on September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance angiography (MRA) of the head rendered to the enrollee on August 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 70544-26 was not billed with the correct modifier.The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  The provider submitted a claim for procedure code 70544-26. The file shows that the procedure is a separate and distinct procedure from approved code 70551; however, code 70544 was not billed with the required -59modifier to allow for payment.Therefore, we decided that the Plan does not have to pay forthe magnetic resonance angiography (MRA) of the head rendered to the enrollee on August 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided from August 1, 2019 to October 24, 2019.You asked the Plan to waive the copayments for specialist visits. You say that you disagree with the charges because you had to keep returning to have stitches removed.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each specialist visit.You received specialist visits from August 1, 2019 to October 24, 2019 for a total of 3 visits. Therefore, you are responsible to pay a $50 copayment per each visit.The total amount you owe is: $150.00. You have been asked to pay the total copayment amount of $150 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided from August 1, 2019 to October 24, 2019.We note your complaint that you had to keep returning to the provider to have stitches removed. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on August 5, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were referred to a gastroenterologist and expected to see the doctor at the appointment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on August 5, 2019.