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

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require skilled services and the continuation of SNF care 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on July 11, 2021.  

You asked the Plan to pay for the PET scan. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed without an appropriate diagnosis code.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Providers must report services with the appropriate diagnosis and service codes that report the service billed to the highest degree of specificity. The claim itself was billed with a diagnosis code of "J90 defined as Pleural effusion, not elsewhere classified" and "E28.39 defined as Other primary ovarian failure". However, the medical records provided indicate there was a more specific part of the body that was the area of concern.    

In this case, this claim cannot be paid as billed due to a generic diagnosis code and the omission of specific codes or modifiers that identify the exact part of the body requiring the image. If more areas of the body that required imaging, the claim should have reflected that with the appropriate codes being billed and submission of the appropriate medical record documentation. Medicare rules for coverage of this claim as billed have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on July 11, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on August 27, 2021.  

You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that the enrollee has a known history of dementia and required medical supervision during transport. You also say that this transport was medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for medical necessity are not met.
  
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 ground mileage and non-emergency ambulance transportation. Our reviewer says that the documentation does not support that the ambulance transport on August 27, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this patient. Our reviewer also found that the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on August 27, 2021.  

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 ground mileage and non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on August 27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit or other outpatient visit (99212) provided on June 17, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the office visit or other outpatient visit. You say that this service was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 the office visit or other outpatient visit (99212) provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on July 2, 2021.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transportation. You say that you were not made aware of authorization being needed for transportation services. You also say that the enrollee was transported for a head laceration from a fall. The Plan denied your request. The Plan says the criteria for coverage are not met.  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 ground mileage and non-emergency ambulance transportation. Our reviewer says that the documentation does not support that the ambulance transport on July 2, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this patient. Our reviewer also found that the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on July 2, 2021.  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 ground mileage and non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transportation (A0428) provided on July 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2021.  You asked the Plan to pay for the laboratory services. 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 a covered benefit.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on July 21, 2021.  

You asked the Plan to provide reimbursement for the eyeglasses. You say that you submitted a receipt with your name on it and do not know what other information the Plan needs. The Plan denied your request. The Plan says there is insufficient information provided to process this claim.  

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.   

We looked at the file and Medicare rules. There is insufficient information to process this claim. There is no evidence that necessary items including provider information, proof of payment, and an itemized list of provided items/services were received by the Plan. Based on this information, we decided that Medicare rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to provide reimbursement for the eyeglasses purchased on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pay for the vision services (92499, 92133) provided from September 20, 2020, to March 26, 2021.  

You asked the Plan to pay for the vision services. You say that you have glaucoma and received these medically necessary services from your usual doctor. The Plan denied your request. The Plan says that these services are not covered by your supplemental/routine vision benefit.  

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. Based on the documentation submitted, the vision services provided are medical in nature. The claim was forwarded to the routine vision vendor for review. The supplemental vision vendor denied the services because they are medical in nature, and the supplemental benefit is for routine vision services such as prescription eyewear and routine vision exams. The Plan states in their denial letter that this claim should have been billed to your medical plan. It is the Plan's job to coordinate benefits, and it is not the fault of the enrollee if a provider bills services to the wrong benefit. The Plan has made no argument for why these services should not be paid under your medical benefits. Therefore, we decided that the Plan has to pay for the vision services (92499, 92133) provided from September 20, 2020, to March 26, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely provided at an alternate and less intense setting such as in a skilled nursing facility as already provided.  

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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the long term care services provided from May 1, 2020, to June 30, 2020.  You asked the Plan to pay for the long term care services. You say that the enrollee had no choice but to continue their stay at this facility. You say that there were no other facilities taking new patients until June 1, 2021. You also say that the services should be paid in full. The Plan denied your request. The Plan says the provider in this case is not a Medicare-certified provider. The Plan also says the claim was processed correctly.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.   Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the long term care services provided from May 1, 2020, to June 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78815).  You asked the Plan to pre-approve PET scan services. You say that this imaging service is medically necessary. The Plan denied your request. The Plan says this service is not covered when requested for the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that an initial FDG PET scan will not be covered for an enrollee who has prostate cancer. This is a request for an initial PET scan for an enrollee diagnosed with prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78815).  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PET scan services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan (78815).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for lead wires (A4557) received on September 3, 2021.  You asked the Plan to pay for the lead wires. You say that this is not inclusive and is separately reimbursable. The Plan denied your request. The Plan says it would not be appropriate to bill for lead wires separately within the 12 months after purchase.  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 A4557 is "Lead wires, (e.g., apnea monitor), per pair."  We find that CPT code A4557 is not supported in the medical record. Specifically, the lead wires for a TENS unit is included in the payment for the unit itself. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead wires (A4557) received on September 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (LTACH).  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short-term additional acute care services that can be safely administered at the current facility until transfer to a lower level of care is appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to LTACH will be considered not medically necessary at this time as it would not be clinically advantageous.  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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 73600) provided to the enrollee on August 28, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a modifier was not billed on the claim to represent the services as separate/distinct.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73600 is a column II code to column I code 73610. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 73600) provided to the enrollee on August 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy (PT) evaluation (97162), therapeutic exercises (97110), gait training therapy (97116), and therapeutic activities (97530) provided on August 24, 2021, and August 26, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the PT evaluation, therapeutic exercises, gait training therapy, and therapeutic activities. You say that you cannot drive to get these services and volunteers charge over $3 per mile. You also say that you are on a fixed income and are improving at this facility. The Plan denied your request. The Plan says these services were rendered by an OON provider and prior authorization was not obtained.  

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.  

The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) evaluation (97162), therapeutic exercises (97110), gait training therapy (97116), and therapeutic activities (97530) provided on August 24, 2021, and August 26, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on August 27, 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 services are not separately payable.  

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 70544 (MRA of the head) and 70551 (magnetic resonance imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on August 27, 2021.