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

We decided that the Plan does not have to pay for transportation services provided to the enrollee on April 10, 2021.

You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for transportation services provided to the enrollee on April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and an x-ray and
waive the coinsurance for an orthosis device provided on April 28, 2021.
You asked the Plan to waive the copayment for a specialist office visit and an x-ray and waive the coinsurance
for an orthosis device. You say that you usually only have a $20 copay for x-ray. You also say that you have
never had to pay the current charges before. The Plan denied your request. The Plan says you have been
charged the correct cost sharing 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 $40
copayment for each specialist visit. Your contract with the Plan also clearly says that you must pay a $20
copayment per visit for flat film x-rays. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for of the total costs for prosthetic devices and related supplies, including braces.
You have been asked to pay $20, which is less than the $40 copayment for a specialist office visit. Office visits
fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You also have
been asked to pay a $20 copayment for an x-ray. X-rays fall within the Outpatient Diagnostic Tests and
Therapeutic Services and Supplies benefit category. You also have been asked to pay $15.27 in coinsurance,
which is 20% of the allowed cost for an orthosis device ($76.36 allowed amount x 20% = $15.27). Orthosis
devices fall within the Prosthetic Devices 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 copayment for a specialist office visit and an x-ray and waive the
coinsurance for an orthosis device provided on April 28, 2021.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital with weakness and pneumonia. You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on December 9, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 7, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that the various denied codes are not supported in the medical record. Specifically, the testing at issue
in this case should be reported with code 81479. Therefore, we decided that the Plan does not have to pay for
the laboratory services provided on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on
March 29, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 physician services provided to the enrollee out of
network on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on November 25,
2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

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 physician services provided to the enrollee on
November 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97140) provided September 28, 2020
You asked the Plan to pay for the physical therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 97140 is not supported in the medical record. Specifically, the provided records do not detail how much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97140) provided September 28, 2020
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to reduce the cost sharing for physical therapy (PT) services you received from
March 10, 2020, to September 25, 2020.
You asked the Plan to reduce the cost sharing for the PT services. You say that the Plan incorrectly assessed a
$40 copayment per visit because this provider is not in-network. The Plan denied your request. The Plan says
that you were charged these copayments correctly because this provider is in-network.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay 40% coinsurance for physical therapy services with an out -
of-network provider.
The Plan says you must pay a $40 copayment for each of the PT services because the provider is in-network.
We do not agree. We do not find that this provider is in-network. This provider does not appear as in-network
on the Plan's current provider directory website. On the provider's own website, he indicates that he does not
accept insurance. Furthermore, on each of the Plan-issued Explanations of Benefits, they list this provider as
out-of-network. Based on the totality of this evidence, we find that these claims should be processed as out-ofnetwork.
For each date of service, this provider billed two codes: 97530 and 97112. The Medicare-allowed
rates for each of these codes are $44.86 and $39.49 respectively, for a total of $84.35 per date of service.
Because the out-of-network coinsurance for PT services is 40%, this would mean that you would be
responsible for $33.74 per date of service ($84.35 x 40% = $33.74), not the $40 per date of service that the Plan
is charging. That means that the Plan must reduce your cost sharing by $6.26 for each date of service.
Therefore, we decided that the Plan has to reduce the cost sharing for physical therapy (PT) services you
received from March 10, 2020, to September 25, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
May 29, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the
enrollee on May 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on September 10,
2020.
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your
request. The Plan says they have tried to reach out to the ordering to verify if they wrote the order for genetic
testing for the enrollee. The Plan states the multiple outreaches had been made however, none of the documents
received yet.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the genetic testing have not been met. There is no written order
from the ordering physician; therefore, we are unable to confirm the requirement of the genetic testing.
All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the
physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a
beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's
specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable
and necessary. Therefore, we decided that the Plan does not have to pay for the genetic testing provided to the
enrollee on September 10, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 11, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. The rules say in a situation where the beneficiary dies, whether any
payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is
pronounced dead by an individual authorized by the State to make such pronouncements.
We looked at the file and Medicare rules. In this case, the file shows that the enrollee's time of death
pronouncement was after dispatch and before the enrollee was loaded onboard the ambulance. Medicare
payment is based on the provider's/supplier's BLS base rate, no mileage or rural adjustment is reported, and the
provider/supplier must use the QL modifier when submitting the claim. In this situation, the correct CPT code
to bill is A0428 for non-emergency services after assessment. Therefore, we decided that the Plan does not
have to pay for the ambulance services provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology examination of tissue using a microscope (CPT code 88305) provided to the enrollee on May 7, 2021, by an out-of-network provider.
You asked the Plan to pay for the pathology services. You say that the doctor's office failed to send in a pre-authorization form for approval. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were 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 the pathology examination of tissue using a microscope (CPT code 88305) provided to the enrollee on May 7, 2021, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroplasty.
You asked the Plan to pre-approve knee arthroplasty. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.
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 knee arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for unilateral primary osteoarthritis of the left knee. The enrollee presented with progressive symptoms including pain impacting sleep or causing fatigue; pain worsened with weight bearing; pain limiting ability to stay fit and healthy; and unable to ambulate two blocks without significant pain and dysfunction. The pain is rated at six out of 10 with moderate activity. The pain is intermittent and is located along the inside aspect and described as aching, penetrating and sharp. Exam of the left knee reveals varus deformity that is correctable. Range of motion is five to 110 with 0 degrees extension lag noted. There is mild effusion. There is tenderness to palpation of medial femoral condyle and medial joint line. However, the x-rays demonstrate tricompartmental pathology. There is limited published, large-scale,
long-term peer-reviewed literature that shows the requested unicompartmental arthroplasty to be an effective and/or safe treatment when there is imaging evidence of more than one compartment pathology. Therefore, the enrollee does not meet criteria for the requested 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 knee arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroplasty.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the IRF services provided on September 22, 2020, through October 2, 2020.

You asked the Plan to pay for the IRF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was not billed with the required occurrence code.

The Plan must follow Medicare rules. Medicare rules say that use occurrence code 50 in place of the service date to report the default discharge date for informational only claims. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the IRF services have not been met. Specifically, this claim was not billed with the required occurrence code for IRF services. Therefore, we decided that the Plan does not have to pay for the IRF services provided on September 22, 2020, through October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve the services. You say that the records provided support the need for care in the skilled nursing facility. The Plan denied your request. The Plan says the records do not show the enrollee requires daily skilled services that can only be provided on an inpatient basis.

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 services. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.