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

We decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided September 2, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this service is always bundled into payment for other services and no separate payment is made.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

CPT code 99100 has a status indicator of "B" on the Physician Fee Schedule meaning that payment is bundled with payment made for other services. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided September 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from March 25, 2020, through December 9, 2020.

You asked the Plan to waive the copayment for the physical therapy. You say that the claims were processed as in-network, but the therapist is no longer a preferred provider. You say that this mistake was made earlier in the year and you had to appeal that time too. The Plan denied your request. The Plan says the copayments applied 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 $40 copayment for Medicare-covered physical therapy from an in-network provider.

You have been asked to pay a $40 copayment for each physical therapy visit. The total amount you owe is
$240 ($40/visit x 6 visits = $240). The physical therapy falls within the "Outpatient rehabilitation services"
benefit category. The records show the physical therapist is a network provider. 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 physical therapy provided from March 25, 2020, through December 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of two aqueous drainage devices for the
enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the records show more than aqueous drainage device per eye.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has glaucoma and is undergoing cataract surgery. The requested
service is for two stent placements. The elements of the coverage rule are not satisfied as only one placement is
covered

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the insertion of two aqueous drainage devices for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve A portable toilet (E0163), to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve A portable toilet. You say that the item is medically necessary. The Plan denied your request. The Plan says the provider is not contracted in your Plan's 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 A portable toilet (E0163), 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 additional power wheelchair accessories (E2313,
E2377) for the enrollee.
You asked the Plan to pre-approve the additional accessories. You say that this is medically necessary. The
Plan denied your request. The Plan says although there are three approved power options on this wheelchair
(tilt, recline and elevating leg rests), there is not a medical need to control these power options through the
joystick.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the additional accessories. Our reviewer
says that the requested additional accessories are not considered medically reasonable and necessary in this
case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of
proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control,
etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.).
The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate
display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech
device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the
upper extremities supports that the enrollee can control any power options through their own individual
switches.
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 additional accessories have not been met. Therefore, we decided that the
Plan does not have to pre-approve additional power wheelchair accessories (E2313, E2377) for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of the Vertiflex Superion interspinous spacer.

You asked the Plan to pre-approve the Superion procedure. You say that you feel that this surgery would be helpful and should be covered. The Plan denied your request. The Plan says this surgery remains experimental at this time.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion device is considered experimental at this time. More research is needed to show safety and efficacy.

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 Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Vertiflex Superion interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 11, 2020.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because the documentation
does not support the Place of Service (POS) code billed on this claim.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing
was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not
appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug
testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided
on December 11, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on January 21, 2021.

You asked the Plan to pay for the hospital discharge day management. You say that the claim should be reconsidered with the attached documents and reprocessed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on April 19, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

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 the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has listed diagnoses of Familial hypercholerterolemia, Mixed hyperlipidemia, and Essential (primary) hypertension. A Comprehensive Cardiomyopathy Panel, a 69-gene screening panel, was ordered. The case file contains a Cardiomyopathy Test Requisition Form, and the results of the testing. There are no additional clinical records to review. The documentation does not support that the genetic testing was medically reasonable and necessary for the enrollee in this case.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided February 17, 2021, to February 22, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that you believe the enrollee met the inpatient criteria for coverage. The Plan denied your request. The Plan says the continued hospital stay was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation did not suggest that the enrollee would require hospital services that would likely cross 2 midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided February 17, 2021, to February 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the gum irrigation (D4921 x 2) provided on June
16, 2021.
You asked the Plan to reimburse you for the dental services. You say that the provider knew the estimated costs
between the patient and insurance. You say that they should have informed you that this procedure was not
covered. You also say that the office did not check into coverage to see what periodontal work actually had to
be done. The Plan denied your request. The Plan says gum irrigation is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the gum irrigation is not among those
covered under this benefit. Additionally, the record shows that you signed a treatment plan acknowledging that
gum irrigation is your responsibility. Therefore, we decided that the Plan does not have to reimburse you for
the gum irrigation (D4921 x 2) provided on June 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is currently in critical condition, only able to walk with assistance and according to medical criteria, the enrollee needs physical therapy to recover some movement. The Plan denied your request. The Plan says the stay is not medically necessary.
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 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. The enrollee was admitted for a stroke. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from April 4, 2021, to April 10, 2021 by an OON provider.
You asked the Plan to pay for the inpatient hospital services. You say that the inpatient level of care was medically necessary, reasonable, and appropriate for the enrollee. The Plan denied your request. The Plan says the enrollee was admitted to an OON hospital 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 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 inpatient hospital services provided from April 4, 2021, to April 10, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on June 18, 2021
by an OON provider.

You asked the Plan to pay for the hospital outpatient clinic visit. You say that the enrollee resides in a nursing
facility and was referred for hearing loss by her home care team. The Plan denied your request. The Plan says
this service was rendered by an OON provider, and the service was not referred by a network provider. The
Plan also says that the service was not approved in advance.

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 hospital outpatient clinic visit provided on
June 18, 2021 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided on November 4, 2019.
You asked the Plan to pay for occupational therapy services. You say that the Plan is required to pay non-contracted providers at the preferred rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules say that the services of an 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 occupational therapy services have not been met. Specifically, the billing provider is a general practitioner, and not a licensed therapist. As such, OT 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 on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 27, 2021 by an out-of-network (OON) provider.

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 were 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 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 office visit provided on April 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine and administration provided on June 24,
2021.
You asked the Plan to pay for tetanus vaccine (90715) and immunization administration (90471). You say that
you suffered a fall and your doctor scheduled a tetanus shot. The Plan denied your request. The Plan says the
diagnosis code submitted Z23, encounter for immunization, is not considered appropriate for a tetanus vaccine.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide tetanus vaccine
(90715) and immunization administration (90471). The Plan follows the same rules.
This service was billed with a non-covered diagnosis. Therefore, we decided that the Plan does not have to pay
for the tetanus vaccine and administration provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9083) provided to you on April 17, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Code S9083 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S9083) provided to you on April 17, 2021.