Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 27, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, or a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and ground
mileage (A0425) provided on April 27, 2021.
You asked the Plan to pay for the ambulance services. You say that the enrollee required an ambulance due to
being bed bound with weakness and altered mental state. You say that the non-emergent transportation was
medically necessary. The Plan denied your request. The Plan says the non-emergent transportation was not
medically necessary.
Medicare pays for ambulance services only when they are medically reasonable and necessary. 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 ambulance services.iewer says that the non-emergency ambulance services are not medically necessary. Our physician
reviewer found the documentation does not support that other means of transport (such as stretcher van) were
contraindicated for the enrollee on April 27, 2021. The reviewer found that the documentation does not support
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully
equipped ambulance can provide for safe transport on April 27, 2021. The reviewer found that the enrollee was
stable and did not require any treatment during transport. The reviewer also found that the documentation does
not support that the ambulance transport on April 27, 2021, was medically reasonable and necessary for the
enrollee.
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 ambulance services have not been met. Specifically, the file does not
support that other means of transport (such as stretcher van) were contraindicated for the enrollee on the date of
service in this case. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance
transport (A0428) and ground mileage (A0425) provided on April 27, 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 this enrollee would benefit greatly from IRF care.
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee
would be safely and equally well serviced with skilled therapy services in an alternate setting. 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. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response without transport (A0998) provided on March 21, 2021.

You asked the Plan to pay for ambulance response without transport. You say that the ambulance was called without you knowing and you refused to be transported to the hospital as you felt that it was not needed. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

Medicare has instituted a waiver related to the Coronavirus pandemic which allows payment for ambulance services without transport if and only if the absence of transport is related to a regional pandemic-caused emergency status. In this case, the case record does not assert or document that the absence of transport was related to the Coronavirus pandemic. Therefore, the waiver does not apply. 

The ambulance company did not provide transport services on March 21, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response without transport (A0998) provided on March 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy (45378) provided on April 21, 2021.

You asked the Plan to pay for a colonoscopy. You say that this is supported in the records. The Plan denied your request. The Plan says the records do not indicate this was diagnostic.

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 45378 is colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure). 

We find that CPT code 45378 is not supported in the medical record. Specifically, the records indicate that this was performed as a screening rather than diagnostic service. Based on this information, we decided that Medicare rules for coverage of a colonoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a colonoscopy (45378) provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of a nursing facility enrollee coded 99380
provided on March 29, 2021.
You asked the Plan to pay for the supervision of a nursing facility enrollee. 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, the CPT Code Manual definition of code 99380 is supervision of a nursing facility patient (patient
not present) requiring complex and multidisciplinary care modalities involving regular development and/or
revision of care plans by that individual, review of subsequent reports of patient status, review of related
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian)
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment
plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.
We find that CPT code 99380 is not supported in the medical record. Specifically, this code has a status code of
"B". A status code of B means that payment for this code is always bundled into payment for other services not
specified. Based on this information, we decided that Medicare rules for coverage of the supervision of a
nursing facility enrollee have not been met. Therefore, we decided that the Plan does not have to pay for the
supervision of a nursing facility enrollee coded 99380 provided on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliances (E0673) provided on September 8, 2020.
You asked the Plan to pay for an intermittent limb compression device and pneumatic appliances. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliances (E0673) provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the wound debridement procedures you had at an outpatient hospital facility from May 20, 2021, to June 10, 2021.

You asked the Plan to reduce the copayments for the wound debridement procedures. You say that you believe you are being billed incorrectly for these services. You said that this should not be considered surgery and you said that these services were done in an outpatient center in the Professional building. The Plan denied your request. The Plan says you were charged these copayments correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for outpatient hospital facility services.

You have been asked to pay a $225 copayment for the wound debridement procedures. The facility where you had these services is considered an outpatient hospital clinic. Your Evidence of Coverage clearly states that the outpatient hospital services copayment of $225 will apply to services in an outpatient clinic. 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 reduce the copayments for the wound debridement procedures you had at an outpatient hospital facility from May 20, 2021, to June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you have leg swelling and a heart condition. You say that you have a very difficult time bending. You say that you use a walker. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT).
You asked the Plan to pre-approve computed tomography (CT). You say that your provider wants your
screenings to be up to date. The Plan denied your request. The Plan says the requested CT scan is not medically
necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 computed tomography (CT). Our
reviewer says that the documentation does not support that the requested services are medically reasonable or
necessary. Our physician reviewer found your provider is requesting coverage for a CT colonography as an
alternative screening procedure. Screening computed tomographic colonography (CTC) is non-covered.
There is no specific clinical rationale for the requested CT scan. Therefore, you do not meet criteria for the
requested services.
We looked at this physician's review, the file, and Medicare rules. Screening computed tomographic
colonography (CTC) is non-covered. Based on this information, we decided that Medicare rules for coverage of
computed tomography (CT) have not been met. Therefore, we decided that the Plan does not have to preapprove
computed tomography (CT).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a replacement procedure of venous
catheter (36581) provided on April 7, 2020.
You asked the Plan to waive the coinsurance for a replacement of venous catheter. You say that you should not
have to pay for a procedure that was initially done incorrectly. The Plan denied your request. The Plan says the
correct coinsurance was 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 25%
coinsurance for each covered surgery or observation room service in an outpatient hospital. You have been asked to pay $839.35, or 25% of the Medicare-allowed charge of $3,357.41, for a replacement
of venous catheter. A replacement of venous catheter 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 coinsurance for a replacement procedure of venous catheter (36581) provided on
April 7, 2020.
Your complaint about being charged for a prior procedure that proved to be ineffective is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 19, 2021, to February 28, 2021.
You asked the Plan to pay for the skilled nursing services. You say that no hospital would admit the enrollee so you believe this should be considered an emergency claim covered under the enrollee's plan. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from November 10, 2020, to February 18, 2021. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from February 19, 2021, to February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment charged for physician services provided on March 11, 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 was charged based on the claim submitted by your provider and the Plan contract agreement.

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 $10 copayment for physician services. 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 $10 copayment charged for physician services provided on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services (45380) provided on January 8, 2021.

You asked the Plan to pay for the colonoscopy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was billed with an incorrect 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, the CPT Code Manual definition of code 45380 is colonoscopy, flexible; with biopsy, single or multiple. 

We find that CPT code 45380 is not supported in the medical record. Specifically, this code was billed with the -74 modifier that indicates a surgery that was discontinued. However, the medical records provided do not support that the procedure was at any time discontinued. Based on this information, we decided that Medicare rules for coverage of the colonoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the colonoscopy services (45380) provided on January 8, 2021.
Appeal type: Lab
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for lab tests. You say that you did not go into the lab on this date
and do not agree that you should be charged for 2 dates of service for lab work. The Plan says that the
deductible amount you are being charged is correct.

We decided that the Plan has to waive the deductible for lab tests.

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 rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles, and coinsurance).

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not submit a complete copy of the applicable Evidence of Coverage
(EOC) for this case. Specifically, the Plan did not submit a section of your EOC clearly stating that your
contract with the Plan includes a deductible, or if it does whether the deductible applies to lab services. We
requested this information, but it was not submitted to us. Without this, we cannot determine whether any
deductible amount applies to this laboratory testing. Therefore, the Plan has not shown that its decision to ask
you to pay $10.32 deductible for lab tests is correct or justified according to your contract with the Plan.
Therefore, we decided that the Plan has to waive the deductible for lab tests.

We also decided that the Plan does not have to waive the cost-sharing for lab tests.

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 $10
copayment per day, per provider for in-network lab tests. These tests were provided on a separate date of
service from your previous testing on April 27, 2021; therefore, a separate copayment applies to this claim.
Therefore, we decided that the Plan does not have to waive the cost-sharing for lab tests.

Therefore, we decided that the Plan has to reduce your total cost-sharing responsibility for this claim from
$10.32 deductible to $10 copayment

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 custom REVO volume management system (L5999).
You asked the Plan to pre-approve custom REVO volume management system. You say that this item is medically necessary. The Plan denied your request. The Plan says the requested item is experimental/investigational.
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 custom REVO volume management system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The requested item is not approved by the Food and Drug Administration and therefore not proven safe and effective for your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of custom REVO volume management system have not been met. Therefore, we decided that the Plan does not have to pre-approve custom REVO volume management system (L5999).