Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON services. You say that the enrollee is in need of a fully customized wheelchair. The Plan denied your request. The Plan says medically necessary care is available 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing and physical therapy services. 
 
You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the services can be managed in an outpatient setting. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health services. Our physician reviewer found that the enrollee has no ulcers. He is at a moderate to supervision level for eating, grooming, bathing, dressing, toileting, and ambulation. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee's care needs appear to be custodial. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing and physical therapy services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided from March 11, 2019 to November 27, 2019.
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says there is no valid referral for this service.
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 from March 11, 2019 to November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab (Prolia) injections (J0897). You asked the Plan to pre-approve the Denosumab. You say that the enrollee has a diagnosis of osteopenia with high risk of fracture. You also say that Prolia would be the best choice and you would recommend Prolia injections for her. The Plan denied your request. The Plan says the Denosumab is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Denosumab. Our reviewer says that Denosumab (Prolia) does not meet coverage criteria. Our physician reviewer found the requested use of Denosumab injections (J0897) is not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Our reviewer also found that the use of Prolia, as requested, is listed as not indicated, not supported and not recommended in any of the compendia. 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 Denosumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab (Prolia) injections (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 2, 2020. 
 
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee. You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of medical necessity. 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 in this case is receiving appropriate care for her needs which includes TPN to allow for ongoing bowel rest to allow for sufficient healing. Her elevated WBC count and severe pain also requires ongoing acute care at this time. However, the enrollee does not require services at the LTACH that are not already available at the current acute care hospital. There was no indication that acute care would be needed past 25 days from now. There are no services available at the proposed LTACH that the enrollee requires now that are not already available and covered at the current acute care hospital. Therefore, without sufficient support made for this request, the LTACH services will be considered not medically necessary for the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the SNF stay provided from November 13, 2019 to December 13, 2019. 
 
You asked the Plan to reduce the coinsurance for the SNF stay. You say that the provider is in-network and that the cost share is incorrect. 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 30% coinsurance for each out-of-network Medicare-covered SNF stay, up to 100 days.  
 
You have been asked to pay a total of $5,551.28 coinsurance for the SNF stay. The SNF stay falls within the "Skilled Nursing Facility (SNF) Care" benefit category. The record shows the provider is an out-of-network provider. See chart below. 
 
 
Dates of Service Service Allowed Amount Coinsurance Member Liability 
November 13, 2019 to November 30, 2019 
SNF stay $11,420.36 30% $3,426.11 
December 1, 2019 to December 13, 2019 
SNF stay $7,083.90 30% $2,125.17 
Total    $5,551.28  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 reduce the coinsurance for the SNF stay provided from November 13, 2019 to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility services provided on December 18, 2019. 
 
You asked the Plan to pay for the nursing facility services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.  
 
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 nursing facility services provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the office visit (99213). You say that you would like reconsideration because this was a follow-up appointment. The Plan denied your request. The Plan says this claim processed correctly because there is no approved referral from your PCP, no referring provider and the services were not listed as urgent/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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 14, 2019 by an out of network (OON) provider.
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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission. 
 
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 that ongoing care needs include hemodialysis, surveillance laboratory studies, oral antibiotics, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 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 the CT colonography provided on February 28, 2020. You asked the Plan to waive the copayment for the CT colonography. You say that it doesn't matter how the procedure is done. You say that it is unfair to charge since colonoscopies are covered. The Plan denied your request. The Plan says the copayment applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each Medicare-covered MRI, CT or PET scan. You have been asked to pay a $150 copayment for the CT colonography. The CT colonography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The CT colonography is considered a diagnostic service. 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 CT colonography provided on February 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a nasal/sinus endoscopy (31237) provided on January 31, 2020, 
 
You asked the Plan to pay for the nasal/sinus endoscopy. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says CPT code 31237 is incidental to CPT code 30905. 
 
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 31237 is nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure). 
 
We find that CPT code 31237 is not supported in the record. Specifically, CPT code 30905 includes the descriptor "separate procedure," which means that is may not be reported separately when billed with a related procedure. In this case, CPT code 30905 has been billed with a related nasal procedure. Based on this information, we decided that Medicare rules for coverage of the nasal/sinus endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a nasal/sinus endoscopy (31237) provided on January 31, 2020,
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 14, 2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 30, 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 procedure codes 80157, 80177, 80201, 80159 and 80173 are not supported. 
 
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 80157 is assay of carbamazepine; free. The definition of code 80177 is levetiracetam drug screen. The definition of code 80201 is assay of topiramate. The definition of code 80159 is clozapine drug assay. The definition of code 80173 is assay of haloperidol.  
 
We find that CPT codes 80157, 80177, 80201, 80159 and 80173 are not supported in the medical record. Specifically, there is no documentation of an assay of carbamazepine; free to support code 80157. There is no documentation of a levetiracetam drug screen for code 80177. There is no documentation of an assay of topiramate to support code 80201. There is no documentation of a clozapine drug assay to support code 80159. There is no documentation of an assay of haloperidol to support code 80173. 
 
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 pay for the laboratory services rendered on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on January 22, 2020. You asked the Plan to pay for the colonoscopy. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 a colonoscopy provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit provided on December 30, 2019. You asked the Plan to waive the coinsurance for office visit. You say that you were told that this procedure would be covered by your insurance, but you were not told that this provider was considered out-of-network with the Plan. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct. 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 50% coinsurance for out-of-network office visit. The allowed amount of the claim is $61.75, resulting in a coinsurance obligation of $30.87. You have been asked to pay 50% coinsurance for office visit. 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 coinsurance for an office visit provided on December 30, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 25, 2019 to November 30, 2019. 
 
You asked the Plan to pay for the services. You say that there have been no denials for the enrollee under the PDPM change went into effect on October 1, 2019. The Plan denied your request. The Plan says this provider must bill their claims with a valid PDPM code, effective October 1, 2019. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report skilled nursing facility services with the appropriate PDPM code. 
 
A review of the claims information shows that HIPPS code KBKD1 was billed in this case on a claim line with revenue code 0120. The dates of service in this case are after the change to the PDPM. According to the new rules laid out by the change in the case-mix system on October 1, 2019, this claim was not billed correctly. HIPPS codes under the new system must be reported on claims with revenue code 0022. 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 skilled nursing facility (SNF) services provided to the enrollee from November 25, 2019 to November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from September 13, 2019 to September 25, 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 from September 13, 2019 to September 25, 2019.