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

We decided that the Plan does not have to pre-approve continuation of SNF services.

You asked the Plan to pre-approve continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.

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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings (enrollee had tube feedings via PEG prior to current hospitalization), or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 

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 pre-approve continuation of SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on May 16, 2021.

You asked the Plan to pay for the CT. 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 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 70450 for the CT has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 (CT) coded 70450 provided on May 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on February 4, 2021.

You asked the Plan to pay for the definitive drug testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the sample was taken in the office setting, meaning that POS 81 is not supported.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 

We looked at the file and Medicare rules. The file does not support that the sample was taken directly by the lab. As such, POS code 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the definitive drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement provided April 20, 2021, to May 13, 2021.

You asked the Plan to waive the copayment for debridement. You say that you feel that the charges are too high because you never saw a physician and only had your dressings changed. 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 a $225 copayment for outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers. 

You received debridement at an outpatient hospital facility from April 20, 2021, to May 13, 2021, for a total of 4 visits. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $225 copayment for each service. The total amount you owe is: $225 (copayment) x 4 (outpatient surgery services) = $900. 

You have been asked to pay the total copayment amount of $900 for debridement. Debridement falls within the outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers 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 debridement provided April 20, 2021, to May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve at the in-network rate an office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve at the in-network rate an office visit. You say that you would like this claim covered at the in-network rate. The Plan denied your request. The Plan says there are in-network providers available to provide the care you need. In addition, you may use the point-of-service benefit.

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 pre-approve at the in-network rate care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. You may also use the Plan's point-of-service option to see this provider. We found no exception that would require the Plan to pre-approve at the in- network rate these items/services. Therefore, we decided that the Plan does not have to pre-approve at the in-network rate an office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. You say that this item is medically necessary. The Plan denied your request. The Plan says this item is statutorily non-covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for procedures on the eye; lens surgery (00142) rendered by the out-of-network (OON) provider on November 19, 2020.

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 anesthesia for procedures on the eye; lens surgery (00142) rendered by the out-of-network (OON) provider on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on April 15, 2021 by an out-of-network provider.

You asked the Plan to pay for the ophthalmology services. You say that the procedures were medically necessary. The Plan denied your request. The Plan says authorization was not obtained by the provider or facility.

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 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 ophthalmology services provided on April 15, 2021 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for ConfirmMDx testing (81551, 88387) provided on February 1, 2021.

You asked the Plan to pay for ConfirmMDx testing. You say that this testing is covered by Medicare. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.

We looked at the file and Medicare rules. The records do not show that the enrollee was being considered for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for ConfirmMDx testing (81551, 88387) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 6, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit (99214). You say that the Plan should pay this claim. The Plan denied your request. The Plan says authorization was not obtained as required.

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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 6, 2021 by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground ambulance services (A0425, A0429) provided January 1, 2021.

You asked the Plan to pay for the ground ambulance services. You say that the ambulance transport provided was medically necessary and should be covered. The Plan denied your request. The Plan says the code was not billed with a proper secondary diagnosis code as required by Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that the criteria for billing A0425 and A0429 have not been met. Specifically, Medicare rules require ground ambulance services to be billed with a specific secondary diagnosis code. In this case, the secondary diagnosis code billed was Z20.828 and not one of the required diagnosis codes as listed in the Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ground ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ground ambulance services (A0425, A0429) provided January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office visits provided on April 14, 2021,
and May 7, 2021.

You asked the Plan to waive the copayment for office visits. You say that the preferred providers are not
specialized enough to meet your needs. 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 a $0
copayment for visits to a preferred primary care provider and a $10 copayments for visits to all non-preferred
primary care providers.

You had an office visit with a non-preferred provider on April 14, 2021. Therefore, you are responsible to pay
the $10 copayment.

You had an office visit with a non-preferred provider on May 7, 2021. Therefore, you are responsible to pay
the $10 copayment.

The total amount you owe is: $20.

You have been asked to pay the total copayment amount of $20 for office visits. Office visits 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 copayment for office visits provided on April 14, 2021, and May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 1, 2021.

You asked the Plan to pay for the office visit (99214), ambulatory continuous glucose monitoring (95251) and
Hemoglobin; glycosylated test (83036). You say that the Plan should pay this claim. The Plan denied your
request. The Plan says a manifestation code was incorrectly billed as primary.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate ICD code.

We find that ICD E0865 is diabetes mellitus due to underlying condition, with a "code first" indication. Based
on this information, we decided that Medicare rules for coverage of the office visit (99214), ambulatory
continuous glucose monitoring (95251) and Hemoglobin; glycosylated test (83036) have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) fine needle aspiration biopsy (10021) provided on May 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the physician provided medically necessary services in good faith. Kindly process the claim towards payment. 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 outpatient office visit (99203) fine needle aspiration biopsy (10021) provided on May 6, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on April 22, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing home. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.

We find that CPT code R0070 is not supported in the medical record. Specifically, this code is a technical component only code. This code was billed with a place of service 31 (skilled nursing facility) However, the enrollee was not in a covered skilled nursing facility stay, which means this code should be billed with place of service 32. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to home or nursing home have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home coded R0070 provided on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the folding walker and seat attachment provided on
December 3, 2020 by an out-of-network provider.

You asked the Plan to pay for the walker (E0143) and seat attachment (E0156). You say that you did not know
rollators had to have prior authorization. The Plan denied your request. The Plan says prior authorization was
not obtained as required.

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 at issue in this appeal. The Plan did not pre-approve the items at
issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the
Plan does not have to pay for the folding walker and seat attachment provided on December 3, 2020 by an outof-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel provided on May 25, 2021.

You asked the Plan to pay for targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements (0242U). You say that the test is covered by Medicare so the claim should be paid. The Plan denied your request. The Plan says the enrollee meets the medical necessity criteria for the panel however the test was billed as a panel of codes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that the Guardant360 cannot be paid as billed with an incorrect CPT code. Medicare rules say the Guardan360 test is billed with CPT code 81479. Based on this information, we decided that Medicare rules for coverage of the Guardant360 test have not been met. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the implanted device check/evaluation provided on
December 30, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were medically necessary and
should be paid. The Plan denied your request. The Plan says the services were not emergent and were not
authorized by the Plan.

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 implanted device check/evaluation provided
on December 30, 2020 by an out-of-network (OON) provider.