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

We decided that the Plan does not have to pay for continuation of SNF services provided from July 11, 2021, through August 9, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services does not meet Medicare coverage criteria. There are no daily skilled nurse or therapist needs.
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 pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for hypokalemia. Regarding rehabilitation services, the enrollee did not receive nor require skilled therapy for the dates in question. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from July 11, 2021, through
August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on July 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for dental services. You say that you were told the provider was in-network prior to your appointment. The Plan denied your request. The Plan says you must obtain covered services, except for emergency care and out-of-area urgent care, from Plan providers.

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 dental services when the services are obtained by a participating Plan provider.

We looked at the file and Medicare rules. Specifically, the services were rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and prophylaxis (D1110) provided on July 29, 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 Coronavirus testing (CPT code(s): 87635 and C9803) provided to the enrollee on August 5, 2020, by a non-Medicare approved/certified freestanding emergency facility.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says this is not a Medicare provider.

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 services have not been met. This provider is a non-Medicare approved/certified freestanding emergency facility. The facilities in question are actually not hospitals and have no affiliation with a hospital. The free-standing ER facilities in question bill with National Provider Identification (N.P.I.) numbers that are registered as a Clinic/Center for Emergency Care. As a result, due to the fact that these facilities are not hospitals, and are not affiliated with a hospital, they are actually unable to obtain Medicare approval/certification. Consequently, According to Chapter 15, Section 15.1 of the Medicare Program Integrity Manual, "No provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. Further, it is essential that each
provider and supplier enroll with the appropriate Medicare fee-for-service contractor." Additionally, Medicare guidance allowing for payment on emergent hospital claims for non-Medicare certified hospitals does not apply to non-Medicare freestanding emergency facilities. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing (CPT code(s): 87635 and C9803) provided to the enrollee on August 5, 2020, by a non-Medicare approved/certified freestanding emergency facility.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says you are receiving ample community support to meet medication and activities of daily 
living needs.

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 the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you are not noted 
to be homebound. You receive daily home health skilled nursing services for the purpose of administering 
insulin. There is no evidence that home health aide services are necessary to assist in the treatment of an injury 
or illness. As such, the requested services are not medically reasonable or 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 home health aide services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427GY) provided on May 24, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say that the ambulance provider should not be making a medical decision and you and you should not be liable for the full charged amount. The Plan denied your request. The Plan says the claim processed and denied correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say diagnosis code Z76.89 should be reported for patients who were transported by ambulance but did NOT require the services of an ambulance crew. Modifier GY should be appended.
We looked at the file and the Medicare rules. The file shows that the ambulance transport was billed with diagnosis code Z76.89 (Persons encountering health services in other specified circumstances) and with modifier GY (item or service statutorily excluded or does not meet the definition of any Medicare benefit). Medicare says that diagnosis code Z76.89 does not support medical necessity and should be appended with a GY modifier. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support, emergency transport, level 1 (A0427GY) provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (99214) provided on 
May 20, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided.

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 $10 
copayment for in-network primary care provider visits for Medicare-covered services.
 
You have been asked to pay a $10 copayment for the in-network Medicare-covered primary care physician 
visit provided. The record shows that the service provided in this case was not an annual wellness visit. 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 the office visit (99214) provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care via telemedicine (CPT code 
99308) provided to the enrollee on August 4, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the documentation indicates that the wound management assessment by the physician on August 
4, 2021, was provided via telemedicine.

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 service have not been met. It does not appear that the provider 
billed this service with modifier 95 in accordance with Medicare rules. Therefore, we decided that the Plan 
does not have to pay for subsequent nursing facility care via telemedicine (CPT code 99308) provided to the 
enrollee on August 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 20, 2020, through December 10, 2020, and from December 14, 2020, through December 19, 2020.

You asked the Plan to pay for the SNF services. You say that it is felt that Medicare coverage applies to the dates of service. The Plan denied your request. The Plan says it was decided to make payment for several days of this time frame. However, the remaining dates did not meet Medicare coverage rules.

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. Custodial care was provided for the dates at issue. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 20, 2020, through December 10, 2020, and from December 14, 2020, through December 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.

You asked the Plan to pre-approve the aquatic therapy. You say that it is felt that this is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 aquatic therapy. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the documentation does not indicate that the requested aquatic therapy
is specific and effective therapy for the patient's condition. The documentation does not reveal an inability to
perform land based therapy. The documentation does not reveal focal deficits or functional deficits on a
physical examination that require formal physical therapy. Exams notes include normal gait, no weakness, no
sensory deficit, and no focal deficit. There is no evidence of radiculopathy, range of motion or strength deficits
on the physical exam. The records do not demonstrate that the unique skills of a professional therapist are
required to safely and effectively provide treatment, that the services can be safely and effectively performed
only by a therapist, or under the supervision of a therapist. The specialized skill, knowledge and judgment of a
qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current
condition or to prevent or slow further deterioration.

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 aquatic therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve aquatic therapy.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

You were admitted for surgical repair of a femur fracture after a fall. Your medical problems are stable. There are 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided on July 17, 2021.
You asked the Plan to pay for out of network services. You say that you were in pain and needed to see a doctor. The Plan denied your request. The Plan says you 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 services provided on July 17, 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 these services are medically necessary. The Plan denied your request. The Plan says that you would be safely and equally well served with skilled therapy services at an alternative level of care.

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.

The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a femur fracture after a fall. Your medical problems are stable. There are 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for contact lenses (V2502) provided on 
August 27, 2021.

You asked the Plan to pay an additional amount for contact lenses. You say that you call prior to your 
appointment to see what your out-of-pocket costs will be. You also say you were told you had a $175 
allowance. The Plan denied your request. The Plan says you exceeded the $175 vision allowance benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan contract says that you receive a $175 vision allowance for routine contact lenses or eyewear 
every year.

We looked at the file and the Plan's rules. The records show you purchased contact lenses for $214. The Plan 
applied your $175 allowance which brings your total cost share due to $39 ($214 - $175 = $39). Based on this 
information, we decided that the Plan's rules for coverage of contact lenses have not been met. Therefore, we 
decided that the Plan does not have to pay an additional amount for contact lenses (V2502) provided on August 
27, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation (90791) provided on August 9, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for psychiatric diagnostic evaluation. You say that you do not believe it should be your responsibility to pay for being out of network as you were told the Plan required you to get the psychological evaluation. You also say that the psychological evaluation has to be done before an implant with pain and spine procedure could be done. The Plan denied your request. The Plan says this provider was not in network, nor was this provider a Medicare-qualified mental health care professional recognized by Medicare.

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 a psychiatric diagnostic evaluation (90791) provided on August 9, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
on August 12, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you went to the hospital. You say that
to deny payment of 2 pills given by a nurse is not okay. You say that you took what you were given as you are
not a medical professional. You also say that this should be covered. The Plan denied your request. The Plan
says the drugs you received are considered self-administered. The Plan says self-administered drugs are
covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not
covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided in an outpatient setting on August 12, 2021.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.