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

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on
March 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that the rendering physician is a hospitalist
physician with the group and depends on the hospital staff to verify eligibility and to obtain the proper
authorization from patient's insurance companies. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.
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 subsequent nursing facility care (99309)
provided on March 19, 2021 by an out-of-network (OON) provider
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional skilled nursing visits.
You asked the Plan to pre-approve 6 additional skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says 6 additional skilled nursing visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 6 additional skilled nursing visits. Our reviewer says that the additional 6 skilled nursing visits are not medically necessary. Our physician reviewer found the provided documentation does not indicate that the enrollee has documented skilled nursing needs. Therefore, the reviewer found that the additional 6 skilled nursing visits are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional skilled nursing visits have not been met. Specifically, the file does not show that the enrollee has skilled nursing needs. Therefore, we decided that the Plan does not have to pre-approve 6 additional skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on September 28, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the surgical pathology services. You say that the patient was seen by a network physician, however, there were no in-network laboratories able to provide the appropriate medical care. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the referring provider was in-network. Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided on September 28, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95861, 95865, 95868) neuromuscular junction testing (95937), somatosensory testing (95938) and central motor evoked potential study (95939) provided on January 8, 2021.
You asked the Plan to pay for the needle electromyography, neuromuscular junction testing, somatosensory testing and central motor evoked potential study. You say that you would like reconsideration because this provider is eligible for payment. The Plan denied your request. The Plan says this provider's taxonomy code (246ZE0600X) is not found within the Medicare Provider Supplier to Healthcare Provider Taxonomy Crosswalk.
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. Specifically, per the Medicare Provider Supplier to Healthcare Provider Taxonomy Crosswalk, this providers taxonomy code is not recognized for Medicare enrollment or payment. Therefore, we decided that the Plan does not have to pay for needle electromyography (95861, 95865, 95868) neuromuscular junction testing (95937), somatosensory testing (95938) and central motor evoked potential study (95939) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on November 30, 2020 and December 14, 2020.
You asked the Plan to pay for the dental services. You say that you were notified that preventive and comprehensive dental services would be covered but there was no mention of an additional premium to be paid. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth.
These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the dental services provided on November 30, 2020 and December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 13, 2020, through August 20, 2020, and billed with a secondary diagnosis code of G93.41.

You asked the Plan to pay for the acute inpatient hospital care as billed. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says the inpatient hospital care billed with a secondary diagnosis of metabolic encephalopathy is not supported in the medical records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis code, G93.41, defined as metabolic encephalopathy. 

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 acute inpatient hospital care as billed. Our reviewer says that the medical documentation does not support the secondary diagnosis as billed for the provided inpatient hospital care. Our physician reviewer found that the documentation supported an admission for noninfective gastroenteritis and colitis, unspecified. The documentation was inconsistent/unclear regarding a diagnosis of metabolic encephalopathy. Even though metabolic encephalopathy is documented on H&P, progress notes and discharge summary, supporting medical record documentation was not found within the record. Member presented with abdominal pain and altered mental status. A diagnosis of advanced dementia is documented in the medical record. The member's daughter reported that the member had a syncopal episode in the vehicle. In the emergency room the member was noted as responsive and answering questions, but only oriented to person. On physical exam "She is alert. Member is at baseline." There is no documentation of worsened mental status. While member presentation warranted consideration of metabolic encephalopathy there was no documentation to support a change in mental status beyond baseline that persisted beyond treatment in the emergency department. The review has determined that the documentation did not support the billed secondary diagnosis code G93.41 defined as metabolic encephalopathy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from August 13, 2020, through August 20, 2020, and billed with a secondary diagnosis code of G93.41.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for professional services provided on July 15, 2021.
You asked the Plan to waive the coinsurance for professional services. You say that you were seen for your long-hauler symptoms due to the coronavirus and should not be charged for the services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for physician/practitioner services, including doctor's office visits. You received professional services on July 15, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $81.08 and 20% of that is $16.22. You have been asked to pay the total coinsurance amount of $16.22 for professional services. Professional services fall within the physician/practitioner services, including doctor's office visits benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for professional services provided on July 15, 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 therapy assistant on January 21, 2021.
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 the services of an occupational therapy assistant (OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 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, and not a licensed therapist. As such, OTA 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 therapy assistant on January 21, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 24, 2021.
You asked the Plan to pay for a lumbar-sacral orthosis. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case.
Specifically, the document submitted as proof of delivery indicates that it requires a signature. The document is not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided on June 24, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87070, 87075, 87077, 87186, 87205)
rendered by the out-of-network (OON) provider on September 17, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 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 laboratory services (87070, 87075, 87077, 87186, 87205) rendered by the outof-
network (OON) provider on September 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records do not show that you require any skilled services on a daily basis in an inpatient setting. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion services provided on May 12, 2021, by an outof-
network (OON) provider.
You asked the Plan to pay for the infusion services. You say that the services are medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the infusion services provided on May 12, 2021,
by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission a skilled nursing facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says the records do not support the need for daily therapy 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 admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no
identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy
services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient
basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission a skilled nursing facility
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of a hematoma (10140) provided on May 28, 2021.
You asked the Plan to pay for the incision and drainage of a hematoma. You say that this was billed correctly. The Plan denied your request. The Plan says this is not separately reportable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If it is necessary to incise and/or drain a lesion as part of another procedure or in order to gain access to an area for another procedure, the incision and/or drainage is not separately reportable if performed at the same patient encounter. We find that CPT code 10140 is not supported in the medical record. Specifically, the documentation indicates that this was a necessary for another procedure and should not be reported separately. Based on this information, we decided that Medicare rules for coverage of the incision and drainage of a hematoma have not been met. Therefore, we decided that the Plan does not have to pay for the incision and drainage of a hematoma (10140) provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the laboratory services (82962, 83036) rendered by the out-of-network (OON) provider on June 15, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 office visit (99214) and the laboratory services (82962, 83036) rendered by the out-of-network (OON) provider on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network
(OON) provider on May 27, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 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 laboratory services rendered by the out-of-network (OON) provider on
May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from July 7, 2021, to July 8, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you called and were told everything would be covered. The Plan denied your request. The Plan says you were charged this copayment correctly.

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 $375 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for one day. You were charged a one-day copayment of $375 for the inpatient hospital services. 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 inpatient hospital services you received from July 7, 2021, to July 8, 2021.