Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says at the present time, medical care is ongoing, and the current amount of therapy is appropriate to meet medical needs.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status and had surgery for a subdural empyema. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 22, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you received a pap smear and should not owe a specialist copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for specialist visits. The medical records show that you received services beyond a preventative gynecological exam on April 22, 2021. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a specialist visit provided on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit provided on February 8, 2021 by a
provider who opted out of Medicare.

You asked the Plan to reimburse you for the office visit. You say that this provider was recommended for your
back pain. The Plan denied your request. The Plan says the provider had opted out of Medicare in 2013.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for
the office visit provided on February 8, 2021 by a provider who opted out of Medicare.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services of home health/hospice aide (G0156) provided from July 6, 2020, to July 16, 2020.
You asked the Plan to pay for the services of home health/hospice aide. The Plan denied your request. The Plan says the treating provider is not Medicare certified and is not eligible to receive payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services of home health/hospice aide have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the services of home health/hospice aide (G0156) provided from July 6, 2020, to July 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80061, 83721, 80050, 83036, 86803, 36415) provided on June 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that this was covered in the past. 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 laboratory services (80061, 83721, 80050, 83036, 86803, 36415) provided on June 11, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486, 87496, 87498,
87541, 87581, 87640, 87798) provided to the enrollee on July 21, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code(s): 87486,
87496, 87498, 87541, 87581, 87640, 87798, remain not supported. The place of service on the CMS-1500 form
line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form
indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also,
the laboratory results submitted indicate the specimen was collected on July 21, 2020 and received by the lab
on July 23, 2020. Of note, the patient resides in Texas (TX) and the billing laboratory is located in Georgia
(GA); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional
information from the provider. Therefore, we decided that the Plan does not have to pay for the laboratory
services (CPT code(s): 87486, 87496, 87498, 87541, 87581, 87640, 87798) provided to the enrollee on July 21,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics (L3020).
You asked the Plan to pre-approve foot orthotics. You say that you need this to treat your metatarsus adductus.
The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on May 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the service was rendered with no adequate time frame to obtain authorization. You also say that the service provided was medically necessary. The Plan denied your request. The Plan says an authorization is required for services rendered by an OON provider. The Plan also says that prior authorization was not 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 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 subsequent nursing facility care (99309) provided on May 12, 2020 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

e decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on May 13, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you told the paramedics they could take your blood sugar and you told them you did not want to be transported to the hospital. You also say that you believe this claim was coded incorrectly. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transport benefit. The Plan also says that if no transport of a Medicare beneficiary occurs there is no Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on May 13, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on May 13, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall and was treated for obstruction from a hiatal hernia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on July 14, 2020.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

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 99239 is not supported in the medical record. Specifically, the documentation submitted does not include a hospital discharge day management note with a recorded duration of time of 31 minutes or more for the billed date of service of July 14, 2020; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT code 99239) provided to the enrollee on July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.

You asked the Plan to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483). You say that you are hoping the epidural will help sooner that weeks of physical therapy. The Plan denied your request. The Plan says there are no notes that you have tried physical therapy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Physical therapy is required before an epidural injection can be approved. Based on this information, we decided that Medicare rules for coverage of injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level (64483) have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease (99072) provided from December 21, 2020, through April 5, 2021.

You asked the Plan to pay for additional supplies, materials, and clinical staff time. The Plan denied your request. The Plan says The Plan says CMS considers these services bundled with the services provided to the enrollee on the same dates of service and is therefore not eligible for separate reimbursement.

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, we have confirmed that code additional supplies, materials, and clinical staff time has a bundled relationship with code 99072 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease (99072) provided from December 21, 2020, through April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on October 24, 2020.
You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
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 95999 is unlisted neurological or neuromuscular diagnostic procedure.
We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that the enrollee had back surgery requiring neurophysiology monitoring. The monitoring rendered was train of four testing. This service is considered a bundled procedure as the cost is included in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on October 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox solution for the enrollee.
You asked the Plan to pre-approve Botox solution. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.
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 Botox solution. Our reviewer says that Botox solution is not medically reasonable and necessary for the enrollee. The patient's records do not show that the patient had tried and failed Dysport or Xeomin. Dysport or Xeomin would not be expected to be less effective or more harmful for the patient as they are essentially equivalent in effectiveness and safety each being a botulinum toxin product. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Botox solution. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox solution have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox solution for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ear wax removal procedure you received
on April 29, 2021.
You asked the Plan to waive the deductible for the ear wax removal procedure. You say that you have not been
charged for this in the past. The Plan denied your request. The Plan says you were charged this deductible
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 $750
deductible for additional services performed on the same day in a physician's office.
According to your Evidence of Coverage, the deductible does not apply to specialist visits. However, the
deductible does apply to additional services performed by a specialist. You had not yet met your deductible at
the time you receive the ear wax removal procedure. 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 deductible for the ear wax removal procedure you received on
April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift mechanism purchased on February 24, 2021.
You asked the Plan to pay for these services. You say that you were not told you had to purchase from a Medicare provider. The Plan denied your request. The Plan says the provider is not Medicare certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows that you received services from a provider not certified in Medicare. 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 seat lift mechanism purchased on February 24, 2021.