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

We decided that the Plan does not have to pay for the laboratory services rendered on July 10, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 17, 2020
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the services provided to you by an out-of-network provider on January 17, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical trays and supplies (A4550 and A4649) provided on April 13, 2021.

You asked the Plan to pay for the surgical trays and supplies. You say that you would like reconsideration because you received authorization for the services rendered. The Plan denied your request. The Plan says CPT codes A4550 and A4649 are not covered by the Ambulatory Surgical Center Outpatient Prospective Payment System.

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 A4550 and A4649 is not supported in the record. Specifically, these codes are not covered under the Ambulatory Surgical Center Outpatient Prospective Payment System. Based on this information, we decided that Medicare rules for coverage of the surgical trays and supplies have not been met.

Therefore, we decided that the Plan does not have to pay for surgical trays and supplies (A4550 and A4649) provided on April 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF care. You say that admission to an SNF is medically necessary for this enrollee, who is having trouble walking on their own. The Plan denied your request. The Plan says while the enrollee may benefit from continued physical and occupational therapy, the records do not support the need for daily therapy on an inpatient basis or any skilled nursing needs. The requested SNF care 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 documentation does not support that this enrollee requires skilled nursing services that require the specialized skill, knowledge and judgement of a skilled professional nurse. The enrollee does require therapy services; however, the documentation does not support that it is medically reasonable and necessary to provide the skilled therapy services on a daily basis at an inpatient level in a skilled nursing facility. As a practical matter, admission to the SNF is not considered medically necessary and reasonable. 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 skilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine services you received from an out-of-network provider on September 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the vaccine services you received from an out-of-network provider on September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the SNF on August 3, 2021 from home. You are not able to ambulate on your own and need maximum assistance with transfers and toileting. You have no skilled nursing services. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 19, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. 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 the services provided by an out-of-network provider on October 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total knee arthroplasty (CPT code 27447), to be provided by an out-of-network provider.
You asked the Plan to pre-approve the service. You say that the enrollee was previously approved to have a knee surgery with the provider in 2018. You state they indicated that the enrollee fractured their shoulder, so the surgery was cancelled. You state the enrollee is now ready to do the surgery, but the authorization was denied. and you do not understand why this was denied, when it was approved for the same provider two years ago. The Plan denied your request. The Plan says the provider is not in-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 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 the total knee arthroplasty (CPT code 27447), to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on January 19, 2021.

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 covered.

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 medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the documentation does not support the billing of code 11721 (debridement of nails) with the -XS modifier was distinct from approved code 11056 (paring or cutting of benign hyperkeratotic lesion).. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the debridement services rendered on January 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on January 3, 2021.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says you must use the Plan's hearing aid provider to use the benefit.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the hearing is were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on January 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 23, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment was made 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 provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on February 4, 2021.

You asked the Plan to pay for a shoulder-arm orthosis. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of a shoulder-arm orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve a CardioMEMS device. You say that the service is medically necessary. The Plan denied your request. The Plan says the device is experimental for the enrollee's diagnosis.
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 a CardioMEMS device. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not fully optimized on his medical regimen, his most recent hospitalization was not for an acute congestive heart failure (CHF) decompensation, and he is currently undergoing evaluation for a treatable cause of his CHF symptoms.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent wheelchair van transport provided on
June 19, 2020.
You asked the Plan to pay for non-emergent wheelchair van transport. The Plan denied your request. The Plan says Medicare does not pay for non-emergent transportation provided by wheelchair vans, taxis, stretcher vans, or ambulettes. The services requested are non-emergent transport services and are for a wheelchair van transport service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergent wheelchair van transport provided on June 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your request. The Plan says routine transportation is not a covered benefit beyond the 50 one-way trip limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. The file shows that the Plan routine
transportation benefit covers 50 one-way trips. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspiration for bone grafting (20939).
You asked the Plan to pre-approve a bone marrow aspiration. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
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 a bone marrow aspiration. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support the medical necessity of bone marrow aspiration during the enrollee's lumbar surgery. Bone marrow aspiration is not considered the standard of care for the treatment of the enrollee's condition. There is insufficient support for this procedure in the peer-reviewed medical literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspiration for bone grafting (20939).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF 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 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or skilled therapy 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 the SNF care have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arterial duplex of lower extremities 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 there is no evidence of previous angioplasty, intractable skin ulcers, intermittent claudication or feeling of coldness in the legs.
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 record indicates that the enrollee has bilateral nocturnal leg pain but us able to walk and run distances pain free. and without cramping. The record indicates that enrollee has arthritis and hyperlipidemia. The physical examination demonstrates normal pulses without signs of arterial insufficiency. The medical record does not support the medical necessity or reasonableness of the requested service as defined by Medicare rules. The elements of the coverage criteria are not satisfied. 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 arterial duplex of lower extremities for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81311, 81317) rendered by the out-of-network (OON) provider on December 2, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the laboratory services (81311, 81317) rendered by the out-of-network (OON) provider on December 2, 2020.