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

 We decided that the Plan does not have to pay for the computed tomography coded 70480 provided on July 20, 2021.  You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that code the computed tomography is a column II code to column I code 70480 for 70450. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography coded 70480 provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for services you received with an out-of-network vascular surgeon on June 23, 2021.  You asked the Plan to waive the coinsurance for the out-of-network specialty services. You say that you had to return to this provider numerous times where either nothing was done or the same test was performed again. You said that the treatment that this doctor performed was unsuccessful. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network specialty care.    You have been asked to pay 50% coinsurance for the out-of-network specialty services. This coinsurance applies regardless of your satisfaction with the services received. 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 services you received with an out-of-network vascular surgeon on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99344) rendered by the out-of-network (OON) provider on August 12, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the home visit for the evaluation and management of a new patient (99344) rendered by the out-of-network (OON) provider on August 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve push handles (K0108).  You asked the Plan to pre-approve push handles. You say that you need this item. The Plan denied your request. The Plan says this item does not serve a primary medical purpose.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    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 pre-approve push handles (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for services you received with an out-of-network vascular surgeon on June 24, 2021.  You asked the Plan to waive the coinsurance for the out-of-network specialty services. You say that you had to return to this provider numerous times where either nothing was done or the same test was performed again. You said that the treatment that this doctor performed was unsuccessful. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network specialty care.   You have been asked to pay 50% coinsurance for the out-of-network specialty services. This coinsurance applies regardless of your satisfaction with the services received. 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 services you received with an out-of-network vascular surgeon on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for services you received with an out-of-network vascular surgeon on July 8, 2021.  You asked the Plan to waive the coinsurance for the out-of-network specialty services. You say that you had to return to this provider numerous times where either nothing was done or the same test was performed again. You said that the treatment that this doctor performed was unsuccessful. The Plan denied your request. The Plan says you were charged this coinsurance 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 50% coinsurance for out-of-network specialty care.    You have been asked to pay 50% coinsurance for the out-of-network specialty services. This coinsurance applies regardless of your satisfaction with the services received. 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 services you received with an out-of-network vascular surgeon on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on October 1, 2020.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee would like to receive inpatient rehabilitation care in the current hospital to receive physical therapy post-surgery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in a lower 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. Our physician reviewer found that 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. 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from May 14, 2021, to May 26, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that these services were provided in good faith and were medically necessary. The Plan denied your request. The Plan says that the services rendered were not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 14, 2021, to May 26, 2021.   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 long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is the appropriate level of care for
this enrollee. The Plan denied your request. The Plan says the services that would be provided in an LTACH
are being provided in the current acute care setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that in this case, the enrollee was admitted with heart failure complicated by acute hypoxic
hypercarbic respiratory failure. The enrollee has had a prolonged hospital course and is not hemodynamically
stable. He continues to receive acute care services, and these have not been denied. The medical record does
not indicate that the enrollee requires services that he is not currently receiving but that would be available at
the LTACH 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the fine needle aspiration biopsy procedure at an outpatient hospital facility on September 30, 2020.  You asked the Plan to waive the copayment for the biopsy procedure. You say that you were not aware of a copayment and believed this would be covered 100%.  You stated that you cannot afford this copayment. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment for outpatient surgery in an outpatient hospital facility.   The enrollee has been asked to pay a $295 copayment for the biopsy procedure. The biopsy procedure falls within the outpatient surgery in an outpatient hospital facility benefit category. 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 the fine needle aspiration biopsy procedure at an outpatient hospital facility on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a ventilator to deliver BiPAP settings is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 a ventilator. Our physician reviewer found that in this case, the record indicates you have acute on chronic respiratory failure from obesity hypoventilation syndrome. This is not a covered indication for the requested service. Furthermore, the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. Therefore, the requested ventilator is 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 a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (80048, 84443, 84450, 84460) rendered by the out-of-network (OON) provider on June 14, 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 (80048, 84443, 84450, 84460) rendered by the out-of-network (OON) provider on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary visit provided on July 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary visit. You say that the enrollee was in an assisted living facility and the provider was not responsible to obtain authorization. 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. Therefore, we decided that the Plan does not have to pay for the domiciliary visit provided on July 13, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial nursing facility care provided on April 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the initial nursing facility care. You say that the enrollee could not choose an in-network provider. You say the facility has an exclusive contract with your company and your doctors are not network providers.  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 service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the initial nursing facility care provided on April 21, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Durolane.  You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your request. The Plan says that you do not have any stated contraindications to the preferred products.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary. You have not tried and failed Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc-One. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet step therapy criteria for Durolane.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 18, 2021.  You asked the Plan to pay for the problem focused limited oral evaluation. You say that this treating facility was on the list of in-network providers that you were sent by the Plan. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a shower chair.  You asked the Plan to pay for a shower chair. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit (99284) provided July 21, 2021.  You asked the Plan to pay for the emergency visit. You say that the enrollee was seen twice in the same day. Please review the attached supporting documentation for both visits. The Plan denied your request. The Plan says this service was reported with another evaluation and management service CPT code 99283 billed on the same date of service by another provider withing the same group and specialty.  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 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity.  We find that CPT code 99284 is not supported in the medical record. Specifically, this service was reported with another evaluation and management service CPT code 99283 billed on the same date of service by another provider withing the same group and specialty. Both claims were billed with the same billing provider/billing NPI. Based on this information, we decided that Medicare rules for coverage of the emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided July 21, 2021.