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

We decided that the Plan does not have to pay for the laboratory services (83631, 83520, 82656, 89055, 87177, 87209) rendered by the out-of-network (OON) provider on March 23, 2021.
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 (83631, 83520, 82656, 89055, 87177, 87209) rendered by
the out-of-network (OON) provider on March 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from IRF care to optimize her level of function prior to returning home. The Plan denied your request. The Plan says the services requested do not meet medical necessity.
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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 1, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee was in a covered Part A SNF stay. As such, payment must be made by the SNF.

The Plan must follow Medicare rules. Medicare rules say that for most Medicare-covered services rendered to a Part A SNF inpatient, payment must be made under arrangements by the SNF and cannot be paid directly by another payer. 

In this case, the enrollee was a SNF inpatient from November 20, 2020 through December 19, 2020. These lab tests are not payable by the Plan as they must be reimbursed by the SNF in question. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Transcutaneous Electric Nerve Stimulation (TENS) 
unit (E0745), provided on February 24, 2021. 
 
You asked the Plan to pre-approve the TENS unit. You say that the item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 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 TENS unit have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Transcutaneous Electric Nerve Stimulation (TENS) unit (E0745), provided on 
February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies represented by code 99072 provided from January 18, 2021 to January 28, 2021.

You asked the Plan to pay for code 99072. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the additional supplies represented by code 99072 provided from January 18, 2021 to January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) provided on July 3, 2021. 
 
You asked the Plan to pay for the CT. You say that you would like the plan to reconsider their denial. The Plan 
denied your request. The Plan says the services billed are not separately payable.  
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 70450 
for the CT has a bundled relationship with code 70496 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 the computed tomography (CT) provided on July 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 26, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate 
place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 26, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pay for IRF care. You say that the services were medically necessary. You also say that you paid the provider $5,400 up front so that they would begin the enrollee's treatment. The Plan denied your request. The Plan says the rehabilitation services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for 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 that the provided documentation shows 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 reviewer found that the enrollee's medical problems are stable and does not have complex nursing or rehabilitation needs. The reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The reviewer found there is no documented need for an intensive, multi-disciplinary rehabilitation program. Therefore, the reviewer found there is not a reasonable expectation that the 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. Specifically, the file shows that there is no documented need for an intensive, multi-disciplinary rehabilitation program. Therefore, we decided that the Plan does not have to pay for the acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00140, 99100) provided February 22, 2021.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. 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. 

We find that CPT code 00140, & 99100 is not supported in the medical record. Specifically, no procedure report was provided to support CPT code 00140. CPT code 99100 has a status of "B" per the CMS Relative Value file and payment for this service is always bundled with payment for another service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00140, 99100) provided February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81226, 81225, 81223, 81227) provided April 
21, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that if a laboratory procedure produces multiple 
reportable test results, only a single HCPCS/CPT code shall be reported for the procedure. 
 
We looked at the file and Medicare rules. This case involves a single service that provided multiple results. 
Only a single code should be billed for this service. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (81226, 81225, 81223, 81227) provided April 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya (tildrakizumab), 100 mg/ml, every 12 weeks.
You asked the Plan to pre-approve Ilumya. You say that the enrollee has tried and failed several topical steroid prescriptions. You also say that this is the appropriate therapy for the enrollee. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, Remicade, Inflectra, or Stelara.
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 Ilumya. Our reviewer says that Ilumya is not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the plan's required drugs, Remicade or Inflectra, and Stelara. The reviewer found that there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria has not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Ilumya (tildrakizumab), 100 mg/ml, every 12 weeks.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Albuterol.
You asked the Plan to pre-approve Albuterol. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Albuterol.
Benefits for Albuterol may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found based on the records provided, the enrollee 
does not have any identifiable skilled nursing service needs. While the enrollee has skilled therapy needs, she 
does not require therapy on a daily basis. She 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for ambulance transport 
provided on May 23, 2021. 
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment is a contractual obligation. 
 
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 $250 
copayment for ambulance transport. 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 $250 copayment charged 
for ambulance transport provided on May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services provided on May 17, 2021.
You asked the Plan to waive the copayment for the podiatry services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received podiatry services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $40 copayment for Podiatry services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received podiatry services on May 17, 2021. You have been asked to pay a $40 copayment for the podiatry services. The podiatry services fall within the Podiatry services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry services provided on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetics testing provided on June 7, 2021.
You asked the Plan to pay for the testing services. You say that the testing was medically necessary. The Plan denied your request. The Plan says the claim processed correctly.
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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the pharmacogenetics testing provided on June 7, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the angiography services provided on February 10, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the requested codes cannot be verified.

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 75774 is Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure). The CPT definition of code 75726 is Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation. 

We looked at the file and the rules. All services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. The medical records provided do not show that the services at issue are a distinct procedural service. 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 angiography services provided on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
November 12, 2020, to December 31, 2020. 
 
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told you 
met your maximum out-of-pocket amount, and you should not be responsible for the copayments. The Plan 
denied your request. The Plan says you have been asked to pay 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 a $35 
copayment for each therapy visit.  
 
You have been asked to pay a $35 copayment for each of the physical therapy visits. ($35 x 9 = $315). The 
physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows 
you met $4,054.39 of your $4,250 maximum out-of-pocket amount.  
 
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 copayments for the physical therapy visits provided from November 12, 
2020, to December 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided August 25, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, & 87798 are not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (32, nursing facility). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided August 25, 2020.