Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health care. 
 
You asked the Plan to pre-approve home health care. You say that the enrollee is bed-bound, cannot walk, and 
needs therapy. The Plan denied your request. The Plan says the denial of authorization for home health care is 
correct. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of home health care have been met. No 
medical records were submitted for review. The Plan made several attempts to obtain records, but none were 
provided. Without supporting records, you have not furnished sufficient information to the Plan to show that 
the enrollee meets criteria for home health care services. Therefore, we decided that the Plan does not have to 
pre-approve home health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services (99443) provided on March 22, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for the telehealth services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says telehealth services are never covered when
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 will never pay for telehealth services rendered by OON providers.
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 telehealth services (99443) provided on March
22, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules.
The documentation shows that the services in question were billed with POS code 81. However, the records
indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This
means that the claim was billed with the incorrect POS code. 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 drug testing services provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on October 26, 2021.
You asked the Plan to pay for the annual wellness visit. You say that you were not aware you had exhausted the benefit. The Plan denied your request. The Plan says the benefit for annual wellness visits had been met at this time.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a home ventilator provided on September 12, 2021.
You asked the Plan to waive the coinsurance for the home ventilator. You say that you feel the charges are too high for the equipment. The Plan denied your request. The Plan says the correct coinsurance was 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).
Your contract with the Plan clearly says that you must pay a 20% coinsurance for each durable medical equipment (DME) item and related supplies, including oxygen equipment. You have been asked to pay $222.23, which is 20% of the allowed amount for the home ventilator ($1,111.13 allowed amount x 20% coinsurance = $222.23). The home ventilator falls within the Durable Medical Equipment (DME) and Related 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 coinsurance for a home ventilator provided on September 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee does not have an appropriate diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Eylea. Our reviewer says that the
requested use of Eylea is not supported. Our physician reviewer found the record indicates that the enrollee has
a diagnosis of vitreous degeneration. The record provided is insufficient to establish a diagnosis of exudative
macular degeneration. Eylea is not indicated for the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to
pre-approve Eylea.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue regeneration (D4266).
You asked the Plan to pre-approve the dental services. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft (D4263) and guided tissue regeneration (D4266).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120),
intraoral - periapical first radiographic image (D0220), and prophylaxis - adult (D1110) provided September 7,
2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the periodic oral exam, intraoral x-ray and dental cleaning. You say that you
were under the impression that the provider was in-network. The Plan denied your request. The Plan says
dental services are not covered when provided OON.
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. The Plan covers the periodic
oral exam, intraoral x-ray and dental cleaning when provided by an in-network dentist.
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of the periodic oral exam, intraoral x-ray and dental cleaning have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), intraoral - periapical first radiographic image (D0220), and prophylaxis - adult (D1110) provided September 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 specialist office visits to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the specialist office visits. You say that you would like to appeal for the enrollee to have office visits scheduled with you. The Plan denied your request. The Plan says the provider is an out-of-network provider where 1 follow up visit was approved prior. An in-network provider was given to the enrollee that provides the same service.
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 6 specialist office visits to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 17, 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 billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on June 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of torus mandibularis (D7473 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee requires these services in order 
for their dentures to fit properly. The Plan denied your request. The Plan says removal of torus mandibularis 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested removal of torus 
mandibularis is not among those covered under this benefit. Therefore, we decided that the Plan does not have 
to pre-approve removal of torus mandibularis (D7473 x 2).
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 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 the enrollee needs rehabilitation because no one in home health is able to help for another 3 weeks. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's current medical condition does not require intensive physician or nursing supervision 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 2, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 12, 2021.

You asked the Plan to pay for the office visit. You say that per the patient's driver's license the patient is male and the diagnosis code N50.89 is appropriate. You say that the claim should be reviewed and reprocessed for payment. The Plan denied your request. The Plan says claims for some services for beneficiaries with transgender and ambiguous genitalia issues, may inadvertently be denied due to sex related edits unless these services are billed properly.

The Plan must follow Medicare rules. Medicare rules say that the KX modifier is now a multipurpose informational modifier and will also be used identify services for transgender and ambiguous genitalia beneficiaries in addition to its other existing uses. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Specifically, the gender listed on the claim does not match the gender from the Medicare database. Since the Medicare database lists a gender/diagnosis mismatch with N50.89, this claim is only payable if modifier -KX is used. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on September 7, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and 
should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on September 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychosocial rehabilitation services (H2017) provided on July 1, 2021, to September 30, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for psychosocial rehabilitation services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 psychosocial rehabilitation services (H2017) provided on July 1, 2021, to September 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 the annual wellness visit (G0439) provided on October 14, 2021.

You asked the Plan to pay for the annual wellness visit. You say that you were not aware you had previously received this service in 2021. The Plan denied your request. The Plan says the benefit for annual wellness visits had been exhausted.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on October 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient physical therapy services (97110, 97116, 
97162) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve OON therapy services. You say that you feel the in-network providers are 
too far from your home, and you will need to travel several times per week for therapy appointments. The Plan 
denied your request. The Plan says there are in-network providers within a reasonable distance from you who 
are able to provide these services. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located 
within reasonable distance and travel time from your home who can provide therapy services. Under Medicare 
rules, this means that contract providers are accessible to you. Therefore, we decided that the Plan does not 
have to pre-approve outpatient physical therapy services (97110, 97116, 97162) to be provided by an out-of-
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on October 1, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component 
(TC) indicator of 8 identifies professional component of clinical laboratory codes for which separate payment 
may be made only if the physician interprets an abnormal smear for hospital inpatient. 
 
 
 
 We looked at the file and Medicare rules. Billed procedure code 85060 has a PC/TC indicator of 8. The file 
shows that the services were not performed in the inpatient hospital setting. Therefore, we decided that the Plan 
does not have to pay for the laboratory services rendered on October 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 10, 2021.

You asked the Plan to pay for the ambulance service. You say that your blood pressure dropped dangerously low. You say that you vomited and passed out. You say that you refused transport to the local hospital. You also say that you feel you could have died due to heart and kidney disease and your blood pressure being so low. The Plan denied your request. The Plan says since there was no transport provided, there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on July 10, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on July 10, 2021.