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

We decided that the Plan does not have to pay for a physician's nail care (G0127, 11720) provided on June 3, 2021, by an out-of-network provider.

You asked the Plan to pay for a physician's nail care. 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 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 physician's nail care (G0127, 11720) provided on June 3, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 10, 2020, to August 16, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the member was never inpatient. You say that the member went to a rehabilitation center. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care. The enrollee has been asked to pay a $225 copayment per day for days 1-6 for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,350 ($225 x 6 days = $1,350). The correct copayment has been applied to the services that were provided. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on August 10, 2020, to August 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray abdomen rendered on February 3, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray abdomen rendered on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on June 22, 2021.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

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 testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. 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 (G0482) provided on June 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the enrollee is currently a fall risk and
needs a SNF in order to improve functional mobility. The Plan denied your request. The Plan says this request
is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled
nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF admission have not been met. Although the enrollee has skilled therapy
needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve a
skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from September 27,
2021, to October 2, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you had kidney stones. You also say
that this was an inpatient stay as you were at the hospital for multiple days. The Plan denied your request. The
Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are
covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not
covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided from September 27, 2021, to October 2, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from June 9, 2021, to June 12, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not feel you owe this copayment. The Plan denied your request. The Plan says the cost-sharing was applied correctly according to the 2021 benefit package.

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 $295 copayment for the first four days of Inpatient Hospital Care.

You have been asked to pay a total copayment of $885 for an inpatient hospital stay ($295  3 days = $885). The services at issue fall within the Inpatient Hospital 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 an inpatient hospital stay from June 9, 2021, to June 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on July 13, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.

We looked at the file and Medicare rules. The file does not contain documentation of an established
relationship between the enrollee and the ordering provider. Without a record showing that this provider is
treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the
Plan does not have to pay for the GeneSight testing rendered on July 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you feel the enrollee needs physician oversight so that her pain is well managed so that she can return home and to decrease risk of infection and incision dehiscing and make sure lab values are stable. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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. The enrollee was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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 medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on August 19, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you feel that this should be considered a follow-up visit to a cataract surgery. 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 $35 copayment for specialist visits. 

The record shows that you had a specialist visit on August 19, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. . 

You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 a specialist visit provided on August 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on July 24,
2021.
You asked the Plan to waive the copayment for ambulance services. You say that you did not request the ride
and cannot afford the charges. 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 $325
copayment for ambulance services.
You have been asked to pay a $325 copayment for ambulance services. Ambulance services fall within the
ambulance 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 ambulance services
provided on July 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information indicates that needs can be met in a skilled nursing facility or at
home with home health care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80048, 84153, 85025, 85610, 85730, P9603) provided on July 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says the services performed were not authorized by the Plan and were not referred by a participating provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for laboratory services (36415, 80048, 84153, 85025, 85610, 85730, P9603) provided on July 26, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthotics rendered on August 3, 2020.
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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that orthotics are covered when specific criteria are met. 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found there is no evidence of an objective physical exam by a medical practitioner indicating that the enrollee's pain would be reduced by restricting mobility of the trunk. There is no evidence of a recent injury or the spine or related soft tissues or a surgery that requires healing. There is no evidence of a deformed spine or objective evidence of weak spinal muscles. The documentation does not support that the LSO was reasonable or medically necessary. The pivot shift test that is described in the documentation as the enrollee's knee giving out while twisting or pivoting is not a true pivot shift test described in orthopedic textbooks and more of a subjective description. There is no objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test) with degree measurements indicating a need for the L1851 knee orthosis. The patient is described as ambulatory but there does not appear to be an objective exam of the patient from the physician. As the prosthesis was not medically necessary, the suspension sleeve was also not medically necessary. The shoulder-elbow wrist hand orthosis (SEWHO) appears to exceed the enrollee's medical need per Medicare medical necessity criteria. There are no objective physical exam findings performed by a treating medical practitioner on the enrollee's shoulder or wrist that indicate an objective need for the shoulder orthosis or wrist orthosis or why the enrollee needs to be in abduction positioning, airplane design. There are no objective physical exam findings performed by a treating medical practitioner on the enrollee's ankle or heel that indicate an objective need for the ankle immobilization, or stability. There are no measurements with degrees of laxity, indications that immobilization will reduce pain on an exam. There are no detailed neuromuscular exam notes documented. There is no evidence of a recent hospital stay indicating this orthosis is part of the treatment plan. The ankle-foot orthosis (AFO) with heel stabilizer was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the orthotics rendered on August 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on July 20, 2021, by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that the provider relies on the facility staff to
verify eligibility and obtain authorization. You say the service was medically necessary. The Plan denied your
request. The Plan says no prior authorization was obtained.
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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 20, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76700 provided on August 20, 2021.

You asked the Plan to pay for the ultrasound. 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 76700 is ultrasound, abdominal, real time with image documentation; complete. 

We find that CPT code 76700 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 covered services are always bundled into payment for other services not specified. This means separate payment for this service cannot be made.

Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76700 provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (K0108) monthly supplies for use of device coded as K1018 (K1019).
You asked the Plan to pre-approve Cala trio therapy system. You say that you believe the enrollee would make an excellent candidate for the Cala Trio device. The Plan denied your request. The Plan says this service is considered experimental and investigational and not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cala trio therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve external upper limb tremor stimulator of the peripheral nerves of the wrist (K0108) monthly supplies for use of device coded as K1018 (K1019).