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

We decided that the Plan does not have to pay for Aranesp injections (J0881, 99213, 96372) provided January 22, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. These conditions include anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML), or erythroid cancers.
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 injections. Our reviewer says that the injections were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of myelogenous leukemia and this treatment is not covered for this diagnosis. 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 injections have not been met. Therefore, we decided that the Plan does not have to pay for Aranesp injections (J0881, 99213, 96372) provided January 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 21, 2021.

You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on March 8, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on March 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 3, 2021, to March 17, 2021.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says a Request for Anticipated Payment (RAP) was not submitted.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record does not show that a RAP was submitted for these services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 3, 2021, to March 17, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy services provided by an occupational therapist on March 24, 2020.
You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. 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 code billed.
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, occupational therapy 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 by an occupational therapist on March 24, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services provided on September 4, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says lab tests must be ordered by the physician who is treating the enrollee.
The Plan must follow Medicare rules. Medicare rules say that tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.
We looked at the file and the rules. The file shows that the enrollee received Corus Coronary Artery Disease (CAD) testing. The file does not show that the tests were ordered by the enrollee's treating physician for the management of a specific medical problem. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the testing services provided on September 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg component alignable system coded as L5910.

You asked the Plan to pre-approve the component described by L5910. You say that this is medically necessary. The Plan denied your request. The Plan says the approved items are more appropriate for the enrollee's condition.

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 component described by L5910. Our reviewer says that the requested item/component is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided documentation, this alignable endoskeletal system as the patient is to get a preparatory prosthesis for rehabilitation which was planned.

The L5645 and L5637 would be more appropriate for the current clinical situation for this patient. The L5910 may be considered at a later date, however. 

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 component described by L5910 have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg component alignable system coded as L5910.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy (0420) and ultrasound (93306) services provided from May 12, 2021, to July 1, 2021.
You asked the Plan to waive the copayment for physical therapy and ultrasound services. You say that the services should be waived as the services were required after taking the covid-19 immunization. The Plan denied your request. The Plan says the cost sharing applied correctly and there are no rules that state services should be waived due to issues with covid-19 immunizations.
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 $30 copayment for Outpatient rehabilitation services and a 10% coinsurance for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $30 copayment for a total of 7 PT visits ($30 x 7 = $210) and a 10% coinsurance for an ultrasound (the allowed amount is $229.23, 10% of that is $22.92) for a total cost sharing of $232.92. Physical therapy and ultrasound services fall within the Outpatient rehabilitation services and Outpatient diagnostic tests and therapeutic services and supplies 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 physical therapy (0420) and ultrasound (93306) services provided from May 12, 2021, to July 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation services (A0428 and A0425) provided on June 19, 2021.
You asked the Plan to pay for the transportation services. You say that you would like reconsideration because the transportation services were medically necessary. The Plan denied your request. The Plan says the member was registered inpatient on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that if an ambulance is used for the transportation of a hospital inpatient to another facility for diagnostic tests or special treatment the ambulance trip is considered part of the DRG, and not separately billable, if the resident hospital is under PPS. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. Specifically, the record indicates that the member was registered inpatient on the billed date of service. This means that payment for the transportation services is included in the DRG and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the transportation services (A0428 and A0425) provided on June 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for endoscopic retrograde cholangiopancreatography (ERCP) provided to the enrollee.

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 these are bundled services that 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 the denied codes is: 

CPT 43261: 

Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple

CPT 43264: 

Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) 

We find that CPT code is not supported in the medical record. Specifically, the payment for these codes are bundled into payment for other codes. They cannot be separately paid. 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 endoscopic retrograde cholangiopancreatography (ERCP) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis provided to the enrollee on July 19, 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 the services were not urgent, emergent, or 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 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 arthrocentesis provided to the enrollee on July 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care (99219) provided on June 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the observation care. You say that pre-authorization is not required for outpatient services. Your physicians rely on the facility to obtain the proper authorization. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited circumstances. The requested care was not urgent or emergent, nor were they pre-approved.
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. No referral was submitted. 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 initial observation care (99219) provided on June 30, 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 anesthesia services (99100) provided October 4, 2020.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for this service is bundled in payment for another 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, we have confirmed that code 99100 has a status of "B". This code is always bundled with another service. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided October 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided on November 17, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of x-rays (D0210) and adjunctive pre-diagnostic test (D0431) provided on April 21, 2021.
You asked the Plan to pay for the dental services. You say that you believed the provider had verified these services would be covered, and you cannot afford this bill on a fixed income. The Plan denied your request. The Plan says the adjunctive pre-diagnostic test is not covered by your dental benefit. The comprehensive exam and x-rays are covered services, but you previously had both of these services provided and paid for in February 2021. Each of these two services may only be covered once every three plan years, so your benefit for these services was exhausted on the date in question. edicare 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. The Plan does not cover services that are not listed in the dental benefits chart in the contract. The Plan can cover one comprehensive exam (D0150) every three plan years. The Plan can also cover one complete series of x-rays (D0210) every three plan years. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit or are requested in a frequency that exceeds what is covered by the benefit. Documentation was provided to show that you had a previous comprehensive evaluation and complete series of x-rays in February, less than three plan years before the date in question. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series of x-rays (D0210) and adjunctive pre-diagnostic test (D0431) provided on April 21, 2021.
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 that in this case the enrollee was admitted with acute hypoxic respiratory failure from coronavirus pneumonia. The record indicates that the enrollee has had a complicated hospital course including bowel perforation and left middle cerebral artery infarct. The record indicates that the enrollee is improving and continuing to require acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement prosthetic leg.
You asked the Plan to pre-approve the replacement prosthetic leg. You say that it is felt that this is necessary since the current prosthesis no longer fits. The Plan denied your request. The Plan says a socket replacement should be attempted prior to replacing the entire prosthetic.
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 replacement prosthetic leg. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found a request was made for an endoskeletal system, above knee or hip disarticulation, alignable system (L5920) which was denied. A socket replacement was instead approved. Based on the provided documentation, the patient had not yet failed a socket replacement to justify the entire prosthesis system to be replaced due to his weight gain. Therefore, without sufficient support made for this request, the 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 replacement prosthetic leg have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement prosthetic leg.endoskeletal system, above knee or hip disarticulation, alignable system (L5920) will be considered not medically necessary.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 5, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (99601) provided March 24, 2021.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule CPT code 99601 has a status of "I" and is invalid for Medicare purposes. Based on this
information, we decided that Medicare rules for coverage of the home infusion services have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion services (99601) provided March
24, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70480) provided on June 26, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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, we have confirmed that code 70480 is a column II code to column I code 70450. 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 the services (70480)
provided on June 26, 2021.