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

We decided that the Plan does not have to pay for the patient lift rendered on November 18, 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 the claim was billed without the correct rental modifier.
The Plan must follow Medicare rules. The rules say that modifier -RR must be billed for durable medical equipment that is rented. We looked at the file and Medicare rules. The claim was not billed with the required -RR modifier. The file shows that the claim was incorrectly billed with the -NU modifier for new equipment, but the equipment was dispensed as a rental. 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 patient lift rendered on November 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF care. You say that you are requesting a reconsideration of the Plan's denial as the patient is ready for rehabilitation. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of inpatient skilled nursing facility care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Buzzaround XL scooter purchased on August 30, 2019.
You asked the Plan to reimburse you for a scooter. You say that the scooter is necessary for any distance and ability to go places with family. The Plan denied your request. The Plan says the information provided that a scooter is not able to be used in your home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The assessment shows your home does not provide adequate access for the operation of the scooter. The file shows that the item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to reimburse you for a power operated vehicle purchased on August 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided to the enrollee on May 9, 2019.
You asked the Plan to pay this claim. You say that the specimen was sent to the lab by a plan provider and the claim should be paid. The Plan denied your request. The Plan says the technical services on the claim cannot be paid as billed under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital or facility. In this case, the enrollee had an outpatient colonoscopy and polyp removal. The polyp was sent to your laboratory for processing and diagnostic evaluation by the Plan facility. The Plan pays for all services provided to the enrollee within the facility claim. Your payment for this service should be submitted to the facility as the facility independently contracted your services. Therefore, we decided that the Plan does not have to pay for pathology services provided to the enrollee on May 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care service provided to the enrollee on June 21, 2019. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. The CPT Code Manual definition of code 99292 is Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes. The file shows that an additional unit of code 99291 and 1 unit of code 99292 was billed on the date of service at issue. We find that CPT codes 99291 and 99292 are not supported in the medical record. The medical records provided do not properly record the additional billed time. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the critical care service provided to the enrollee on June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 31, 2019 by an out of network (OON) provider.
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 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 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 December 31, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that the additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee is diagnosed with right knee stiffness, pain in the right knee, and presence of an artificial right knee joint who is seeking authorization for additional physical therapy visits. Per records she has had 30 visits for the right knee and hip pain. The enrollee states that she needs therapy for the knee and hip area for knee manipulation and a tear in the right. The enrollee had a right total knee arthroplasty with manipulation under anesthesia, and right hip gluteus medius tendinopathy. On 4/15/20 the PT note revealed she has had instruction on gait training, home exercise program, and modalities. She has made improvements in pain, knee range of motion with 0 in extension and 130 flexion. She has minimal changes in strength, increased weight bearing, has gait deviations due to muscle fatigue and weakness. The requested therapy is generally not accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy visits and the documentation reveals she has been instructed on a home exercise program. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (92015) provided on December 24, 2019.
You asked the Plan to pay for a refraction. You say that this should be covered. The Plan denied your request. The Plan says refractive services are not covered under your benefit plan unless rendered by an EyeQuest Routine Vision Care Provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers refraction when it's provided as part of an annual routine eye exam provided by an EyeQuest Routine Vision Care Provider. We looked at the file and the Plan's rules. The records show that the refraction at issue was not provided as part of an annual routine eye exam provided by an EyeQuest Routine Vision Care Provider. Based on this information, we decided that the Plan's rules for coverage of a refraction have not been met. Therefore, we decided that the Plan does not have to pay for a refraction (92015) provided on December 24, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on July 17, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on July 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Abraxane, Carboplatin, Pembrolizumab, Ondansetron Hcl, Dexamethasone Sodium Phosphate, Palonosetron Hcl and Aprepitant for the enrollee.
You asked the Plan to pre-approve these drugs. The Plan denied your request. The Plan says that the enrollee does meet step therapy criteria.
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 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 drugs. Our reviewer says that Abraxane, Carboplatin, Pembrolizumab, Ondansetron Hcl, Dexamethasone Sodium Phosphate, Palonosetron Hcl and Aprepitant are not medically reasonable and necessary for the enrollee in this case. The documentation does not indicate the enrollee has had a trial of Taxol or Taxotere. Nor does it indicate there is a contraindication to those drugs or to the supportive medications needed for their safe administration. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for these drugs. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Abraxane, Carboplatin, Pembrolizumab, Ondansetron Hcl, Dexamethasone Sodium Phosphate, Palonosetron Hcl and Aprepitant for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent positron emission tomography (PET) scan rendered on November 5, 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 the services were not medically necessary.
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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has been treated for diffuse large B-cell lymphoma. The only clinical information submitted for review is the report of a PET scan done November 15, 2019 which states it was compared to a scan of May 1, 2019 and showed no evidence of cancer. The records do not support that the subsequent PET scan at issue was 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 pay for the subsequent positron emission tomography (PET) scan rendered on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 15, 2019.
You asked the Plan to pay for the dental service. You say that the last oral exam that you received was on April 29, 2019, more than 6 months before your next oral exam on November 15, 2019. You say that this oral exam should be covered. The Plan denied your request. The Plan says the frequency limit for oral exams has been exceeded. The record shows that the Plan paid for an oral exam that you received on September 27, 2019, less than 6 months before
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 oral exam every 6 months has been exceeded. The record shows that the Plan paid for an oral exam that you received on September 27, 2019. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on November 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on November 22, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that you do not have access to the enrollee's finances. The Plan denied your request. The Plan says you were charged this cost sharing 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). The enrollee's contract with the Plan clearly says that the enrollee must pay a $200 copayment for each ambulance trip. The enrollee had one ambulance trip. The Plan charged $200 for these services. This means that the enrollee's estate has been asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services provided on November 22, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 skilled nursing services provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing home health services 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 skilled nursing need shown.
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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the request for 6 more skilled nursing services is not medically necessary to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. The enrollee has had prior skilled nursing which should have been adequate in disease process education. She had no evidence of complex wound care, enteral feedings, or other professional skilled nursing need therefore additional skilled nursing visits are not 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing home health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on January 6, 2020 by an out of network (OON) provider.
You asked the Plan to pay for wound care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 wound care provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided on October 25, 2019 to a hospital inpatient.
You asked the Plan to pay for the heart-lung machine services. You say that this is a medically necessary services which must be paid. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. Although these services may be appropriate, since they are non-physician services, payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a heart/lung machine provided on October 25, 2019 to a hospital inpatient.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the domiciliary home visit (99334) provided on November 6, 2019. You say that you would like reconsideration because it is the responsibility of the facility to acquire authorization for this service. The Plan denied your request. The Plan says utilization of network providers is required when possible and 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 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 November 6, 2019 by an out of network (OON) provider.