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

We decided that the Plan does not have to pay for the office visit rendered on October 28, 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 services are not separately payable.

The Plan must follow Medicare rules. The rules say that preoperative visits are included in the global surgical package. 

We looked at the file and Medicare rules. The file shows that procedure code 99214 (office visit) was billed on the same day as minor surgical procedure code 11621 (excision of malignant lesion). Payment for the office visit is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home oxygen concentrator.
You asked the Plan to pre-approve these services. 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 for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic obstructive pulmonary disease (COPD) and the notes indicate he is on home oxygen. Qualifying oximetry or blood gas measurements are not provided. There is no historical qualifying data in the submitted documentation. The records do not show that the criteria for coverage are met; therefore, the services are not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home oxygen concentrator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve PET scan. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because another test (brain PET scan) would be more appropriate at this time.
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 PET scan. Our reviewer says that the enrollee does not meet the Medicare criteria for this scan. Our physician reviewer found the PET scan requested does not directly relate to a PET/CT which is done of the brain to evaluate dementia. Rather, this is a scan used for oncologic applications. The enrollee in this case is not suspected of having cancer. As the requested test is not being done for an oncologic condition, the request would not meet the Medicare requirements for coverage 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998),
provided on February 18, 2021.
You asked the Plan to pay for the ambulance service. You say that you were having an attack from you head to
your heart and stomach. You say that your husband called 911 as you felt this was an emergency situation. You
say that you were feeling better after receiving oxygen. You also say that you felt that going to the hospital was
not necessary. The Plan denied your request. The Plan says ambulance services without transport is not a
covered benefit.
The Plan follows Medicare rules. Medicare rules say that if an ambulance responds to a call but does not
transport the person for whom the call was placed, Medicare does not pay for the service.
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 ambulance service. Our reviewer says
that the ambulance services was not medically necessary. Our physician reviewer found you did not require
emergency medical services (EMS) care or transport due to being stable hemodynamically. Therefore, the
reviewer found that the ambulance services will not be considered medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the ambulance service have not been met. Specifically, the file indicates that
you were stable hemodynamically and did not require transportation to the hospital. Therefore, we decided that
the Plan does not have to pay for the ambulance response and treatment, no transport (A0998), provided on
February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the office visit provided on February 25, 2021.

You asked the Plan to waive the copay for the office visit. You say that a wellness visit has no copay. The Plan denied your request. The Plan says the claim processed 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 $20 copay for primary care doctor visits. 

The file shows that you received an annual wellness visit. You were not charged a copay for these services. You also received an office visit for the treatment of conditions that do not fall under the annual wellness visit benefit category. You have been asked to pay a $20 copay for the office visit. The services fall within the physician services benefit category.

This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the office visit provided on February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus vaccine received on May 5, 2021.

You asked the Plan to pay for the Tetanus vaccine. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services received are not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Tetanus vaccine. Therefore, we decided that the Plan does not have to pay for the Tetanus vaccine received on May 5, 2021.

Benefits for the Tetanus vaccine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept transport furnished by a volunteer ambulance (A0432) provided on February 2, 2021.

You asked the Plan to pay for the paramedic intercept transport. You say that you would like this claim to be reviewed, and additional payment to be made. The Plan denied your request. The Plan says because the enrollee was not actually transported by ambulance, this expense is not covered by the enrollee's benefit plan.

The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.

The Plan has confirmed that the billing provider does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept transport furnished by a volunteer ambulance (A0432) provided on February 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 3, 2021.
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 the codes are denied due to being submitted with modifier 26.
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 the denied codes is: CPT 80053: comprehensive metabolic panel CPT 82607: Cyanocobalamin (Vitamin B-12)
CPT 85025: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the services were billed with modifier 26 - professional component. Per the Medicare Physician's Fee Schedule, the denied codes have a Professional Component Technical Component (PCTC) indicator of 9 and cannot be billed with modifier 26 professional component. Therefore, billing procedures with modifier 26 would not be covered. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network for cardiac rehabilitation.
You asked the Plan to pre-approve the referral. You say that you cannot find a provider near you. The Plan denied your request. The Plan says there are in-network providers available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network for cardiac rehabilitation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you could be treated safely and effectively at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms which would require acute treatment. You have shown improvement with loose association and concrete reasoning. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others and were compliant with your treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee must follow in-network guidelines.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound dressing (A6196) provided on October 12, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for wound dressing. You say that this is covered by Medicare. The Plan denied your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 wound dressing (A6196) provided on October 12, 2020 by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on February 18, 2021.

You asked the Plan to pay for the ambulance service. You say that you could not breathe, threw up, and had chills. You say that your physician advised you to call an ambulance. You say that once you were stable, the paramedic advised you of what over the counter medications you could take and advised against going to the hospital due to the threat of Covid-19. You also say that this company is listed under your providers. The Plan denied your request. The Plan says ambulance response and treatment with no transport is not covered by Medicare.

The Plan follows Medicare rules. Medicare rules say that if an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. 

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 ambulance service. Our reviewer says that the ambulance transport would not have been medically necessary. Our physician reviewer found the documentation does not support that ambulance transportation would have been medically necessary in this case, regardless of community-wide emergency medical services (EMS) protocols. The reviewer found that you did not require EMS care or transport due to being stable hemodynamically and only requiring outpatient services based on EMS evaluation findings. Therefore, the ambulance transportation would not have been considered medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Specifically, the file shows that you were stable hemodynamically and only required outpatient services based on the EMS evaluation findings. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on February 18, 2021.
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 service is medically necessary. The Plan denied
your request. The Plan says the service is 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 considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found your medical problems are stable and you have no complex nursing or rehabilitation
needs. While the documentation does support a need for physical and/or occupational therapy, there is no
documented need for a intensive, multi-disciplinary rehabilitation program.
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. Specifically, medically necessary services can be
obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF)
admission and services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says that needs could be met in a custodial level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the requested admission is medically reasonable and necessary. Our physician reviewer found the enrollee does qualify for SNF coverage. Although the enrollee does not have documented skilled nursing needs, the enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below her baseline. The enrollee has made some progress while in the acute care hospital. The documentation does not yet show a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, cannot be provided at a lower level of 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

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.