Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on June 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the enrollee was seen in an office setting and supported by the medical records. Please review the claim with the attached medical records and process the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the outpatient office visit (99214) provided on June 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient mental health telehealth visit you had on September 7, 2021.  

You asked the Plan to waive the copayment for the outpatient mental health telehealth visit. You say that you were told by the provider and by the Plan that this copayment would be waived. The Plan denied your request. The Plan says you were charged this copayment correctly.  

The Plan says that they have phone records showing that you called them to ask about copayments being waived on August 2, 2021.  On that date, you were advised that the copayment waiver ended on March 31, 2021.  

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 outpatient mental health visits.   

You have been asked to pay a $30 copayment for the outpatient mental health telehealth visit. the outpatient mental health telehealth visit falls within the outpatient mental health visits benefit category. There is no provision in your contract for a waiver of this 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 copayment for the outpatient mental health telehealth visit you had on September 7, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

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 you are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency endotracheal intubation (31500) provided September 3, 2021.

You asked the Plan to pay for the intubation services. You say that this point of service is listed 21not an office level service, therefore you have to bill under the physician assistant doing services. Please see attached medical records. The Plan denied your request. The Plan says the claim needs to be re-billed under the supervising physician as per CMS rules regarding physician assistant coverage.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Specifically, physician assistant services should be billed under the supervising physician.

Based on this information, we decided that Medicare rules for coverage of the intubation services have not been met. Therefore, we decided that the Plan does not have to pay for emergency endotracheal intubation (31500) provided September 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on June 23, 2021.

You asked the Plan to pay for the services provided. You say that the report supports the diagnosis. The Plan denied your request. The Plan says the code was not reported with an appropriate diagnosis code.

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. We find that CPT code 88305 is not supported in the medical record. Specifically, the billed code does not accurately describe pathology services of the common bile duct. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hallux valgus and interphalangeal fusion to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve hallux valgus and interphalangeal fusion to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve hallux valgus and interphalangeal fusion to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments charged for ambulance transport, emergency room services, inpatient care provided on July 18, 2021 to July 19, 2021.  You asked the Plan to waive these copayments. You say that you were not happy with the care you received and do not feel you should have to pay the copayments. The Plan denied your request. The Plan says these copayments were charged based on the services provided and the Plan contract agreement.  The Plan has paid their portion of each bill based on their contract with you and these copayments are your portion of the cost of each service covered by 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 cost share for each service provided. You have been asked to pay the correct amount for each service 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 charged for ambulance transport, emergency room services, inpatient care provided on July 18, 2021 to July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious disease screening (87481, 87500, 87640, 87641, 87798) provided on July 14, 2021.

You asked the Plan to pay for infectious disease screening. You say that this is supported by the records. The Plan denied your request. The Plan says this is not a covered screening.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, infectious disease screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for infectious disease screening (87481, 87500, 87640, 87641, 87798) provided on July 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy visits.  

You asked the Plan to pre-approve additional physical therapy visits. The Plan denied your request. The Plan says additional 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 that the member has previously been treated with outpatient therapy and should be independent with a home exercise program. Our reviewer says that the additional therapy services are not an appropriate duration and frequency for treatment of the member's medical condition and therefore 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 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve blocks.

You asked the Plan to pre-approve the blocks. You say that this is medically necessary, and the enrollee would benefit from having the injections. The Plan denied your request. The Plan says there is not enough scientific evidence to show a benefit from this procedure.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the requested genicular nerve block of the knee is not medically reasonable or 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1851).

You asked the Plan to pre-approve the orthosis. You say that the brace will be beneficial for the enrollee's treatment at your office. The Plan denied your request. The Plan says the records do not support that the request is medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the requirements listed in the Local Coverage Determination (LCD): Knee Orthoses (L33318) for Medicare coverage of the requested knee orthosis. The available records do not document the enrollee has knee instability on physical examination or that the enrollee has had recent injury to or a surgical procedure on the knee. 

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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1851).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the acupuncture services provided from July 19, 2021 to July 30, 2021.

You asked the Plan to pay for the acupuncture services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

 The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. For services performed on or after January 21, 2020, Medicare will now provide limited coverage of acupuncture for patients with chronic low back pain (CLBP). The case file shows you have chronic low back pain. The Plan did not provide any type of review regarding you meeting Medicare criteria for Acupuncture services. The Plan provided no evidence that you do not meet Medicare criteria and the Plan's Evidence of Coverage criteria for Acupuncture services. Therefore, we decided that the Plan has to pay for the acupuncture services provided from July 19, 2021 to July 30, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed.  You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624).  

You asked the Plan to pre-approve the ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says genicular nerve ablation is considered investigational and is not covered. 

 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental and is the subject of ongoing clinical trials. It is not the standard of care.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve ablation procedure (64624).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for foreign object removal from an open
wound performed on July 2, 2021.
You asked the Plan to waive the copayment for the foreign object removal. You say that you did not go into an
operating room and the copayment should not apply. 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 a $275
copayment for outpatient surgical procedures.
You have been asked to pay a $275 copayment for the foreign object removal. Foreign object removal from an
open wound falls within the Outpatient Surgery.
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 foreign object removal from an open wound
performed on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on January 27, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug test (G0482) rendered by the out-of-network (OON) provider on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient mental health telehealth visit
you had on August 31, 2021.
You asked the Plan to waive the copayment for the outpatient mental health telehealth visit. You say that you
were told by the provider and by the Plan that this copayment would be waived. The Plan denied your request.
The Plan says you were charged this copayment correctly. The Plan says that they have phone records showing
that you called them to ask about copayments being waived on August 2, 2021. On that date, you were advised
that the copayment waiver ended on March 31, 2021.
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 outpatient mental health visits.
You have been asked to pay a $30 copayment for the outpatient mental health telehealth visit. the outpatient mental health telehealth visit falls within the outpatient mental health visits benefit category. There is no provision in your contract for a waiver of this 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 copayment for the outpatient mental health telehealth visit you had on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient varicose vein surgery (stab phlebectomy of the superficial varicosities) for the enrollee.

You asked the Plan to pre-approve the services. You say that the enrollee's varicosities are superficial and too large to be treated with sclerotherapy. The Plan denied your request. The Plan says there is no evidence of significant reflux on the venous doppler study.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while the criteria allow for phlebectomy of varicose veins in the absence of reflux, there must be documentation of bulbous varicose veins greater than 3 mm in diameter. In this case, there is a disconnect between the physical examination and the venous duplex. On physical examination, it is documented that there is a ropy varicose vein of the lateral thigh and proximal calf of about 3mm in diameter. This was apparently interrogated on the duplex where the duplex "imaged the thigh levels both medial and lateral aspect and there are no evidence of any varicosities and branches." 

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 outpatient varicose vein surgery (stab phlebectomy of the superficial varicosities) for the enrollee.