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

 We decided that the Plan does not have to pay for the laboratory services provided on December 10, 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. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on February 22, 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 subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on February 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on April 7, 2021.  You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice until after the services were provided. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) and ground mileage (A0425) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON consultation services. You say that you have had good success with other doctors from this same facility. The Plan denied your request. The Plan says the service requested may be provided in-network.  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 consultation services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgery for the removal of ruptured breast implant to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these services are available in network.  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 surgery for the removal of ruptured breast implant to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have a bilateral foot injury and the custom orthotic will help your stability. 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.
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 SNF care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a lumbar-sacral orthosis and a shoulder orthosis provided on March 8, 2021.  You asked the Plan to pay for a lumbar-sacral orthosis and a shoulder orthosis. You say that the records provided support that the claim in dispute should be reprocessed and paid. The Plan denied your request. The Plan says the guidelines for coverage have not been met.  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 pay for a lumbar-sacral orthosis and a shoulder orthosis. Our reviewer says that the criteria for coverage of the requested items have not been met. Our physician reviewer found the records provided do not indicate that the elements of the coverage criteria for a lumbar-sacral orthosis are satisfied.  The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested shoulder orthosis. Supporting records from the ordering provider were not submitted.  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 lumbar-sacral orthosis and a shoulder orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis and a shoulder orthosis provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interpretation of the abdominal ultrasound provided on July 6, 2021, billed with code 76705.  You asked the Plan to pay for the billed code 76705. You say that multiple exams were done on the date of service. The Plan denied your request. The Plan says the Column 2 code was not billed with a required modifier.  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 the billed code 76705 is a column II code to column I code 93976 which was also billed on this date of service. This claim has not been billed with an appropriate modifier to bypass the edit. 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 interpretation of the abdominal ultrasound provided on July 6, 2021, billed with code 76705.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that the enrollee is medically ready to discharge from the hospital. You say that the enrollee's provider and family feels that rehabilitation is needed. The Plan denied your request. The Plan says the enrollee does not have any daily skilled nursing needs. The Plan says that the enrollee has not had a change in function that needs daily skilled therapy services.  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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis.  He is medically stable and can receive further rehab services at a lower level of care.  Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube.  He is medically stable without any acute exacerbations of chronic medical problems.  His physical function is at or near his baseline and he can receive services at a lower level of care.  Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve physician services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve physician services to be provided by an OON provider. You say that the requested physician services with the OON provider are medically necessary. The Plan denied your request. The Plan says that there are in-network providers available to you.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 physician services to be provided by an OON provider. Our reviewer says that the requested physician services with the OON provider are medically appropriate in this case. Our physician reviewer found based on the documentation provided for review, the enrollee is appropriate for kidney transplant evaluation by the requested transplant center. The enrollee meets criteria for going OON for evaluation.  This is a practice that would be considered 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 physician services to be provided by an OON provider have been met. Therefore, we decided that the Plan has to pre-approve physician services to be provided by an out-of-network (OON) provider.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on July 7, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you believe you should only be responsible for the $90 emergency room copayment. The Plan denied your request. The Plan says you have been charged this amount correctly.  The Plan says that your claim has been adjusted to show that you only owe the $225 copayment for the CT scan and not the $90 copayment for the ER visit.  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 $225 copayment for advanced imaging services.  You have been asked to pay a $225 copayment for the CT scan. The Plan contract says that if any advanced imaging services are received as part of an emergency department evaluation, then you will only pay the advanced imaging copayment, not the emergency room copayment.  The Plan has reprocessed your claim and is not charging you the ER visit copayment.  You are only being charged a copayment for the CT scan, which falls within the advanced imaging 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 computed tomography (CT) scan you had on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the technical component (TC) of the somatosensory testing and electroencephalogram (EEG) digital analysis provided during an inpatient surgery on July 20, 2020.  You asked the Plan to pay for the TC of the neuromonitoring provided. You say that you feel that reimbursement should be made for these items as they are not provided by the facility. The Plan denied your request. The Plan says the TC of these services cannot be paid.  The Plan must follow Medicare rules. Medicare rules say that items and non-physician services provided during an inpatient hospital stay are included in payment to the facility. These cannot be separately paid.  The TC of a service does not include physician work. As such, the TC is solely items and non-physician services which cannot be separately paid as the enrollee was a hospital inpatient. Therefore, we decided that the Plan does not have to pay for the technical component (TC) of the somatosensory testing and electroencephalogram (EEG) digital analysis provided during an inpatient surgery on July 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on May 14, 2021 and  May 21, 2021.  You asked the Plan to pay for the chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.  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. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on May 14, 2021 and May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management services (99239) provided on February 20, 2021.  You asked the Plan to pay for code 99239. 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, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of service, type of service, procedure code, place of service and billed amount. The first claim was paid on May 13, 2021 by the Plan. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services (99239) provided on February 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a laparoscopic cholecystectomy (47562) provided on November 25, 2020, by an out-of-network provider.  You asked the Plan to pay for a laparoscopic cholecystectomy. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care 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 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 a laparoscopic cholecystectomy (47562) provided on November 25, 2020, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) and allergy testing (95018) provided on May 19, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the clinic visit. You say that you were not aware that the visit required a prior authorization and was referred there by your Oncologist. 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 hospital outpatient clinic visit (G0463) and allergy testing (95018) provided on May 19, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable home ventilator for the enrollee.  You asked the Plan to pre-approve a portable home ventilator. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the requested device would be used in a BiPAP mode that could be provided with a BiPAP.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 portable home ventilator. Our reviewer says that a portable home ventilator is not medically reasonable and necessary for the enrollee. The patient was diagnosed with COPD and chronic respiratory failure after being recently admitted to the hospital for encephalopathy and acute on chronic respiratory failure. No other testing documentation was provided. The provided documentation does not clearly show that the patient had tried or would be inappropriate for BiPAP with back up rate and average volume-assured pressure support (AVAPS) to provider her needs. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable home ventilator.  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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator for the enrollee.