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

 We decided that the Plan does not have to pay for the ConfirmMDx testing provided on August 3, 2021.  

You asked the Plan to pay for the testing services. You say that the biopsy occurred prior to the test ordered. The Plan denied your request. The Plan says the enrollee does not meet criteria for the test.  

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered under certain medical indications.  

We looked at the file and Medicare rules. The medical records provided do not indicate the enrollee was being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services provided from October 8, 2020, to November 3, 2020.  

You asked the Plan to pay for acupuncture. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is not a physician was not working under the direct supervision of a physician, physician assistant, or nurse as required for coverage of acupuncture services.  

The Plan must follow Medicare rules. Medicare rules say that auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision by a physician, physician assistant, or nurse practitioner/clinical nurse specialist.   

We looked at the file and Medicare rules. This provider is a licensed acupuncturist - which is a type of auxiliary personnel - and the record does not show that the provider was acting under the appropriate level of supervision for these acupuncture services. Based on this information, we decided that Medicare rules for coverage of acupuncture have not been met. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from October 8, 2020, to November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99223) provided October 4, 2020.  You asked the Plan to pay for the initial hospital care. You say that you would like this claim reprocessed The Plan denied your request. The Plan says the physician claim is billed with a place of treatment as inpatient; however, according to the facility claim these services were rendered as outpatient.  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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.  We find that CPT code 99223 is not supported in the medical record. Specifically, this code has been billed with a place of service (POS) of 21 indicating inpatient services. However, the facility has used bill type 131 indicating these services as outpatient. Therefore, these services appear to have been billed with an incorrect POS code based on the facility's use of bill type 131. Based on this information, we decided that Medicare rules for coverage of the initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided October 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided from August 1, 2021, through August 2, 2021.

You asked the Plan to waive the copayment for the emergency care. You say that you believe that this copayment should be waived. The Plan denied your request. The Plan says after reprocessing and partially approving payment, the charged copayment is correct for the emergency room care provided.

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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for the emergency care. This care falls within the emergency care 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 emergency care provided from August 1, 2021, through August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on June 9, 2021. 

You asked the Plan to waive the copayment for an office visit. You say that this was your initial visit and annual physical. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $10 copayment for physician/practitioner services, including doctor's office visits.   

The medical records show that you received services beyond an annual wellness exam on June 9, 2021. Therefore, you are responsible to pay the $10 copayment.   

You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a new sleep study with associated new continuous positive airway pressure (CPAP) machine.  

You asked the Plan to pre-approve additional sleep study medical services. You say that additional care is medically necessary for your medical condition. The Plan denied your request. The Plan says additional services are not medically necessary at this time based on the previous medical services provided.  

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 additional sleep study medical services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that you are a 76-year-old male with sleep-disordered breathing since 2006, prescribed servo-ventilation and cervical collar use at night. A request was made for a new sleep study and new CPAP machine. It was reported that you had failed BiPAP and ResMed Aircurve, making several adjustments over time. You have recently completed a sleep study and 10 or more previous ones. Your treating physician does not recommend another sleep study or a new device.  

Therefore, without sufficient support made for this request, the sleep study and CPAP device will each be considered 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 sleep study medical services have not been met. Therefore, we decided that the Plan does not have to pre-approve a new sleep study with associated new continuous positive airway pressure (CPAP) machine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that Medicare will pay for an inpatient rehabilitation facility (IRF) admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the eye exam and visual field examination provided on August 31, 2021.  

You asked the Plan to pay for the eye exam and visual field examination. You say that you were not aware you would not be allowed to seek an appointment or possible treatment if you feared there was a problem. You say that the denial of payment should be removed. The Plan denied your request. The Plan says that only one routine exam is covered per calendar year.  

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. The claim was submitted as a routine eye exam and a medical eye exam. The Plan has not forwarded any medical records Without medical records we are unable to determine if the Plan was justified in denying for a routine exam. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the eye exam and visual field examination provided on August 31, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202) and ultrasound (97035) provided March 2, 2021.

You asked the Plan to pay for the diagnostic office visit. You say that spinal manipulation is a covered service on this enrollee's Plan. You would like to get this improperly processed claim reprocessed correctly. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) and ultrasound (97035) provided March 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional PT visits.  

You asked the Plan to pre-approve additional PT visit. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is 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 PT visit. 

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 you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your 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 PT visit have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.  

You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that the requested features are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested features 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 pre-approve an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested features are not medically necessary as the enrollee does have use of hands and can operate and control the power options using the switches that are included in the basic wheelchair. Furthermore, the documentation does not indicate that the enrollee requires the requested harness and electronic connection.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 3, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve modification of a manual wheelchair to an electric wheelchair for the enrollee.  

You asked the Plan to pre-approve the modification. You say that this is medically necessary. The Plan denied your request. The Plan says there needs to be a face-to-face evaluation by the treating physician indicating the medical need for a second power wheelchair.  

The Plan follows Medicare rules. The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 the modification. Our reviewer says that the requested modification is not medically reasonable or necessary. Our physician reviewer found that based on the medical records provided, there is no documentation that the modification of a manual wheelchair to an electric wheelchair meets Medicare criteria for medical necessity. The records do not include a current face-to-face examination between the enrollee and his medical provider explaining the need for the modifications given that records show the enrollee already has a power wheelchair which is not reported to be irreparably damaged or lost.  

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 modification have not been met. Therefore, we decided that the Plan does not have to pre-approve modification of a manual wheelchair to an electric wheelchair for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport provided on June 23, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. You say that your blood sugar level dropped and when the paramedics arrived, they immediately started an intravenous treatment and within ten minutes your blood sugar started to go back up and you felt well and did not need to be transported to the hospital. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without transport, there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 23, 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 and treatment, no transport provided on June 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on June 29, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network services provided to the enrollee on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

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 the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for computed tomography (CT) lower extremity (73700) provided May 18, 2021.  

You asked the Plan to pay for CT scan. You say that the provider performed the services in question and should be paid accordingly. Please review the attached documents and process for payment per the provider contract. The Plan denied your request. The Plan says procedure exceeds the maximum number of services allowed for a single date of service. 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 73700, 26, RT is computed tomography, lower extremity.  

We find that CPT code 73700, 26, RT is not supported in the medical record. Specifically, the procedure exceeds the maximum number of services allowed for a single date of service. Based on this information, we decided that Medicare rules for coverage of CT scan have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) lower extremity (73700) provided May 18, 2021.