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

We decided that the Plan does not have to pay for out-of-network services provided to the enrollee on October
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 the enrollee did not have prior authorization for out of network are.

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 to the enrollee
on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day services (99239) provided to the enrollee on December 22, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is "hospital discharge day management of more than 30 minutes." 

We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 99238 and CPT 99239 are reported by time spent providing hospital discharge day management. In this case, documentation does not include the time spent providing this service and, therefore, more than 30 minutes cannot be confirmed.

We looked at this coder'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 pay for hospital discharge day services (99239) provided to the enrollee on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided on December 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. 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 services (99072) provided on December 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the arm you had on May 17, 2021.
You asked the Plan to waive the copayment for the MRI. You say that although you have never had an MRI before, you have never had to pay this much for a hospital visit in the past. 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 $250 copayment for diagnostic radiology services (except x-rays). You have been asked to pay a $250 copayment for the MRI. The MRI falls within the diagnostic radiology services (except x-rays) 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 the magnetic resonance imaging (MRI) of the arm you had on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received 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. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for congestive heart failure and infected lower extremity wounds associated with chronic
lymphedema. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve (G0249) provided March 26, 2021 to April 25, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that you were notified on March 15th that future claims wound not be paid as durable medical equipment bus as diagnostic lab with a $40 copayment The Plan denied your request. The Plan says the claims were reprocessed correctly with the correct copayment per the Evidence of Coverage.

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 $40 copayment for Medicare covered radiological diagnostic services, not including x-rays.

You have been asked to pay $80 ($40 + $40) copayment for the diagnostic services. The diagnostic services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve (G0249) provided March 26, 2021 to April 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (21310, 30903, 99285) provided on October 1, 2020.

You asked the Plan to pay for an emergency room visit. You say that this should be covered. The Plan denied your request. The Plan says these codes are not documented.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT codes 21310, 30903, and 99285 are not supported in the medical record. Specifically, no medical records have been submitted. Without this information, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (21310, 30903, 99285) provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tempus gene panel (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321) provided on November 23, 2020.
You asked the Plan to pay for a Tempus gene panel. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed 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. To report a CGP service, test providers should
use CPT code 81479 at this time. We find that CPT codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, and 81321 are not supported in the medical record. Specifically, these codes were used to report a CGP service, which should be billed with 81479. Based on this information, we decided that Medicare rules for coverage of a Tempus gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus gene panel (81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, 81321) provided on November 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the FreeStyle Libre CGM and supplies (K0553 and K0554) provided on February 5, 2021.

You asked the Plan to pay for the FreeStle Libre CGM and supplies. You say that you would like reconsideration because these supplies were authorized by the Plan. The Plan denied your request. The Plan says these supplies are not documented in the member's medical record.

The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the FreeStle Libre CGM and supplies. Our reviewer says that multiple notations in the provided records indicate that the member is not checking their glucose levels regularly. Our physician reviewer found there is no clear documentation that the beneficiary's insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results particularly given that she is reported to be non-compliant with glucose monitoring. 

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 FreeStle Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libre CGM and supplies (K0553 and K0554) provided on February 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient clinic visit (G0463) provided on July 14, 2020.
You asked the Plan to pay for an outpatient clinic visit. You say that this is supported in the records. The Plan
denied your request. The Plan says this is not documented.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code G0463 is hospital outpatient clinic visit for assessment
and management of a patient.
We find that CPT code G0463 is not supported in the medical record. Specifically, the medical records do not
include documentation of a clinic visit. The records submitted pertain only to imaging services. Based on this
information, we decided that Medicare rules for coverage of an outpatient clinic visit have not been met.
Therefore, we decided that the Plan does not have to pay for an outpatient clinic visit (G0463) provided on July
14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on April 22, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you do not feel like you should be responsible for this. The Plan denied your request. The Plan says the correct copayment has been 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 $250 copayment for outpatient diagnostic tests/advanced imaging services. 

You have been asked to pay a $250 copayment for a CT scan. The correct copayment has been applied to the services that were provided. A CT scan falls within the outpatient diagnostic tests/advanced imaging services 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 CT scan provided by a participating provider on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the treadmill (A9300) purchased January 20, 2021.

You asked the Plan to pay for the treadmill. You say that you feel that this should be covered because if this was offered last year during the pandemic it should still be offered this year since the pandemic is ongoing. The Plan denied your request. The Plan says Per the temporary COVID-19 Policy, you may use your Wellness Allowance towards the purchase of exercise equipment that you can use at home. Only purchases made during 10/1/2020-12/31/2020 submitted for reimbursement by the deadline will be eligible for reimbursement.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

Per the temporary COVID-19 Policy, you may use your Wellness Allowance towards the purchase of exercise equipment that you can use at home. Only purchases made during 10/1/2020-12/31/2020 submitted for reimbursement by the deadline will be eligible for reimbursement. This benefit was not offered to Plan members and is not offered in the 2021 Wellness allowance benefit. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the treadmill (A9300) purchased January 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating ambulatory facility on April 27, 2021.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you have never had a copayment for this in the last 22 years. The Plan denied your request. The Plan says the correct copayment has been 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 $275 copayment for outpatient surgery/outpatient hospital facility.

You have been asked to pay a $275 copayment for a diagnostic colonoscopy. Evidence was provided that showed that the colonoscopy that was provided was diagnostic in nature; therefore, the correct copayment has bene applied. A diagnostic colonoscopy falls within the outpatient surgery/outpatient hospital facility 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 diagnostic colonoscopy provided by a participating ambulatory facility on April 27, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Keytruda. Our reviewer says that the medication is medically necessary. Our physician reviewer found keytruda has activity in bone predominant hormone refractory prostate cancer status post endocrine therapy and taxotere. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee has a past medical history of coronavirus pneumonia and is living at home with ongoing weakness after completing acute care, skilled nursing care and home physical therapy. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 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 there is no valid physician order.

The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a
physician who has furnished a consultation or treats an enrollee for a specific medical problem.

The file does not contain documentation of an established relationship between the enrollee and the ordering
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
rendered on April 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 5,
2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you already paid for the
ambulance transport on January 2, 2021, in full. The Plan denied your request. The Plan says this copayment
was charged correctly because the patient also had an ambulance trip on January 5, 2021.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $275 copayment per one-way trip for ambulance services.
The enrollee has been asked to pay a $275 copayment per one-way trip for the ambulance services. The
ambulance trip report from this date show that the enrollee received a transport to his home on January 5, 2021,
when he was discharged from the hospital. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
ambulance services provided on January 5, 2021.