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

 We decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427) and ground mileage (A0425) provided on July 19, 2021.  You asked the Plan to pay for the transportation services. You say that the services should be covered. The Plan denied your request. The Plan says the claim was denied correctly.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.   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 the transportation services. Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the provided documentation does not support the provision of advanced life support (ALS) ambulance services. The reviewer found that the provided documentation does not support the diagnosis of fever. As such, the reviewer found that the billing of A0427 for diagnosis code R509 is not supported.  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 transportation services have not been met. Specifically, the file does not support that the need for an advanced life support (ALS) ambulance. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, emergency transport (A0427) and ground mileage (A0425) provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on June 20, 2021.  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 are not covered.  The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all durable medical equipment (DME) and supplies.  We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on June 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the gene panel provided on September 16, 2021.  You asked the Plan to pay for the services provided. You say that the treatment sought was a covered service. The Plan denied your request. The Plan says one code must be submitted for the panel.  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. The records show that the genetic testing was billed with multiple codes. 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 services provided have not been met. Therefore, we decided that the Plan does not have to pay for the gene panel provided on September 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office visit (CPT code 99204) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the office visit. You say that you need a team for specialist to look at your medical files and consider if you have options. You state that you are in severe pain constantly and the level of pain is getting worse. The Plan denied your request. The Plan says the service is available in-network and there are no extenuating circumstances related to geographic access, compelling continuity of care making it medically necessary that future care come only from this provider, or unique medically recognized qualifications of the requested out-of-network provider to justify prior authorization of out-of-network benefits.  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 the office visit (CPT code 99204) to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on July 14, 2020.   You asked the Plan to pay for the occupational therapy services. You say that the medical records required to process the denied claim are attached. The Plan denied your request. The Plan says the code is not appropriate for the service billed.  The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapy assistant on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from August 4, 2021, to August 5, 2021.  You asked the Plan to pay for the self-administered drugs. You say that you do not know what this denial is for. The Plan denied your request. The Plan says the self-administered drugs are not Part B covered.    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 pay for the self-administered drugs provided from August 4, 2021, to August 5, 2021.   Benefits for the self-administered drugs 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: DME/ Orthotics
Decision: Partially Favorable

 We decided that the Plan has to waive part of the coinsurance for gauze, non-impregnated, sterile (A6219) and collagen dressing, sterile. We also decided that the Plan does not have to waive all of the coinsurance for gauze, non-impregnated, sterile (A6219) and collagen dressing, sterile A6021) provided on June 8, 2021.   You asked the Plan to waive the coinsurance for gauze, non-impregnated, sterile and collagen dressing, sterile. You say that the actual materials received can be obtained for less than $75 retail. The Plan denied your request. The Plan says you were charged the correct cost sharing amount.  We decided that the Plan has to reduce the coinsurance for gauze, non-impregnated, sterile and collagen dressing, sterile.  Medicare rules say that 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 says that you must pay 20% coinsurance for in-network medical supplies. The coinsurance the Plan charged you was calculated incorrectly. The Plan charged you a coinsurance of $109.98. The coinsurance amount you should have been charged is $88.68 ($443.40 allowed amount x 20% coinsurance = $88.68).  The Plan says that you must pay $109.98, which is more than 20% coinsurance for gauze, non-impregnated, sterile and collagen dressing, sterile. Based on your contract with the Plan, however, you can only be asked to pay $88.68, which is 20% coinsurance for these dressings. Therefore, we decided that the Plan has to reduce the amount of the coinsurance for gauze, non-impregnated, sterile and collagen dressing, sterile from $109.98 to $88.68.  We decided that the Plan does not have to waive the coinsurance for gauze, non-impregnated, sterile and collagen dressing, sterile.   Medicare rules say that 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 says that you must pay 20% coinsurance for in-network medical supplies. Your coinsurance for these claims is $88.68 ($443.40 allowed amount x 20% coinsurance = $88.68). Therefore, we decided that the Plan does not have to waive the coinsurance for these medical supplies.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve six (6) doctor's office visits (CPT code 99214 x 6) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the enrollee needs to be seen by their specialist before they can establish with a new primary care provider. The Plan denied your request. The Plan says they will uphold the denial to this facility for neurosurgery as that facility does NOT have neurosurgery providers. The Plan states if the enrollee seeks neurology visits, they can see their current neurologist associated with Gritman at Palouse Neurology.  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 six (6) doctor's office visits (CPT code 99214 x 6) to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a combination skin protection and positioning seat cushion.  You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the enrollee does not have absent sensation or significant postural asymmetries due to a covered diagnosis.  The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.   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 requested item. Our physician reviewer found that there is no evidence of significant postural asymmetries due to a condition outlined in the coverage criteria. The documentation does not support that the requested combination skin protection and positioning seat cushion is 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 requested item have not been met. Therefore, we decided that the Plan does not have to pre-approve a combination skin protection and positioning seat cushion.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat capsule endoscopy, gastrointestinal tract imaging, intraluminal, esophagus through ileum, with interpretation and report (91110) provided January 6, 2022 to February 6, 2022.  You asked the Plan to pre-approve a wireless capsule endoscopy. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says it is not reasonable to subject the enrollee to another prep and ask for a third examination. Multiple attempts were made to obtain additional information to support medical necessity from the provider without success.  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 a wireless capsule endoscopy.   Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found after two wireless capsule endoscopy (WCE) studies, there is not an indication for a third.  The documentation does not support that yet another wireless capsule endoscopy (WCE), gastrointestinal tract imaging, intraluminal, esophagus through ileum, with interpretation and report is medically reasonable and necessary for the enrollee in this case.  Additionally, multiple attempts were made to obtain additional information from the provider as to the medical necessity for a third procedure, no further information was received via phone or fax.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat capsule endoscopy, gastrointestinal tract imaging, intraluminal, esophagus through ileum, with interpretation and report (91110) provided January 6, 2022 to February 6, 2022.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation of wheezing (94060), plethysmography (94726), and diffusing capacity (94729) provided on August 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the evaluation of wheezing, plethysmography, and diffusing capacity. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were referred and rendered by OON providers. The Plan also says that an authorization was not requested or obtained prior to these 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 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 evaluation of wheezing (94060), plethysmography (94726), and diffusing capacity (94729) provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for speech therapy provided on May 18, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for speech therapy. You say that you would like the Plan to reprocess this claim and pay for this due to medical necessity. The Plan denied your request. The Plan says these services were provided by an out-of-network provider.  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 speech therapy provided on May 18, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 12, 2021, to August 16, 2021.  You asked the Plan to pay for the SNF care. You say that you had pneumonia. You also say that you were not discharged until August 16, 2021 as a result. The Plan denied your request. The Plan says the SNF care was not medically necessary.  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 pay for the SNF care. Our reviewer says that you did not meet the Medicare criteria for SNF care. Our physician reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. You did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. You did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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. Specifically, the file shows that you did not require daily skilled care during the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 12, 2021, to August 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the standard wheelchair (CPT code K0001).  

You asked the Plan to pre-approve the standard wheelchair. You say that you need the wheelchair. The Plan denied your request. The Plan says there is no documentation that you had a mobility related limitation that prevents you from completing one or more activities of daily living (ADL). The Plan states there is no physical therapy (PT), occupational therapy (OT) notes showing limitations or why you cannot use the walker for ADL's.  

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.   

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 standard wheelchair. Our physician reviewer found there is inadequate documentation of the severity of your personal mobility deficit. No face to face, in-person physical examination documenting the severity of your weakness and gait instability has been provided. No documentation from physical therapy or occupational therapy has been provided documenting the extent of your personal mobility deficit. Based on the medical records provided there is conflicting documentation as to whether your mobility deficit can or cannot be helped by the use of a walker. Some provided records indicate you are ambulating about your room in the assisted living facility with your walker. No face-to-face physical examination documenting the severity of your weakness and gait instability has been provided. No documentation from physical therapy or occupational therapy has been provided documenting the extent of your personal mobility deficit. There is documentation that you can safely operate a manual wheelchair.  

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 standard wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve the standard wheelchair (CPT code K0001).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the naturopathic services you received on September 22, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services.   The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for the naturopathic services you received on September 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on June 12, 2019, to June 19, 2019.  You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.  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 $265 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care/in-network.    You have been asked to pay a $265 copayment per day for days 1-4 for an inpatient hospital stay. The total amount you are being asked to pay is $1,060 ($265 x 4 days = $1,060). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 an inpatient hospital stay provided by a participating provider on June 12, 2019, to June 19, 2019.