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

We decided that the Plan does not have to pay for duplex scan of lower extremity arteries or arterial bypass
grafts (93925) provided on October 14, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the duplex scan. You say that your services are treated as an emergency service
in the nursing home and home health settings as these facilities are required to treat potential fractures and
other conditions within a four-hour window. 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 duplex scan of lower extremity arteries or arterial
bypass grafts (93925) provided on October 14, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve True Metrix glucose test strips.  You asked the Plan to pre-approve test strips. You say that this is medically necessary. The Plan denied your request. The Plan says there is a preferred product that has been prescribed.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no justification in the records for why you cannot use the preferred brand in this case. There is no evidence as to why the non-preferred brand is needed. Therefore, the non-preferred brand is not covered.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve True Metrix glucose test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive audiometry threshold evaluation and speech
recognition test (92557) and audiologic function test (92567) provided on August 6, 2020 by an out of network
(OON) provider.
You asked the Plan to pay for the audiology services. You say that please find attached the referral, the hearing
assessment and audiogram. Please review and reconsider this claim for 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 has network providers
available who can provide 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 comprehensive audiometry threshold evaluation
and speech recognition test (92557) and audiologic function test (92567) provided on August 6, 2020 by an out
of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc for the enrollee.  You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the information provided by the doctor does not meet Medicare guidelines.  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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the records do not document a trial and failure of conservative measures for the enrollee's condition including treatments such as physical therapy, analgesics or intra-articular corticosteroids.  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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on August 23, 2021.  You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment and you did not know that the facility failed to get preauthorization for this patient, so you treated this patient anyway. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 domiciliary or rest home visit (99336) provided on August 23, 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 for the enrollee.
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 the enrollee can safely receive the services needed 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 above.
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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure,
congestive heart failure and kidney failure. The enrollee's medical conditions are stable. There are no medical
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that this patient will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the routine venipuncture (36415), and the laboratory service (83036) rendered by the out-of-network (OON) provider on September 27, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463), the routine venipuncture (36415), and the laboratory service (83036) rendered by the out-of-network (OON) provider on September 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on July 9, 2021, and billed under code 36215-59.  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 Medicare billing criteria were not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code and when necessary, the required modifier.  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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the provider billed Current Procedural Terminology (CPT) 36215-59 (selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family) with modifier 59 appended.  Although, code 36215 can be reported separately from CPT 36901, documentation should be clear to support CPT guidelines for reporting these procedures separately.  Procedure report does not include enough documentation to support coding 36215 separate from 36901.  A query should be made before billing.  Per CPT guidelines "For the purposes of reporting dialysis access maintenance services, the arterial inflow to the dialysis circuit is considered a separate vessel.  If a more proximal arterial inflow problem separate from the peripheral dialysis segment is suspected, additional catheter placement and imaging required for adequate evaluation of the artery may be separately reported.  If a catheter is selectively advanced from the dialysis circuit puncture beyond the peri-anastomotic segment into the inflow artery, an additional catheterization code may be reported.  For example, 36215 may be used to report image-guided retrograde catheter placement into the inflow artery and into the aorta, if necessary.  Per procedure report: Arteriovenous Access: Left Brachial Cephalic AVF" "Attention was then turned toward the arterial inflow.  Selective catheterization of the brachial artery was performed, and an arteriogram obtained".  Therefore, modifier 59 cannot be verified, and a query would be made.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 9, 2021, and billed under code 36215-59.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 8, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider was not enrolled in the Medicare program on the date of service at issue in this appeal.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue was not enrolled in the Medicare program for the May 8, 2020 date of service. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 8, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Accu-Chek test strips for the enrollee.

You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says that covered supplies are available through the retail pharmacy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the test strips. Our reviewer says that the requested items are considered medically reasonable and necessary in this case. Our physician reviewer found the records shows that the enrollee was on the 670g Medtronic pump in August 2021; however, the note also says that the enrollee will be up for an upgrade in one month to 770g. The 670g uses the contour strips, and the 770g uses the Accu-Chek guide strips. Presumably this enrollee is upgrading to the 770g and is therefore requesting the Accu-Chek guide strips. Using these strips will help facilitate proper use of the pump system. 

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 test strips have been met. Therefore, we decided that the Plan has to pre-approve Accu-Chek test strips for the enrollee.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on July 28, 2021.

You asked the Plan to pay for the shingles vaccine. You say that you were told by the Plan that the shingles
vaccine was covered. The Plan denied your request. The Plan says this is not a covered Part B drug or service.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine.
The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to shingles.
Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on July 28, 2021.

Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on August
11, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that the visit should have
been charged to the VA instead of the Plan. The Plan denied your request. The Plan says you have been
charged the correct cost sharing 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 $50
copayment for each specialist office visit.

You have been asked to pay a $50 copayment for the specialist office visit. Please note that while the VA
referred you to this provider, the copayment applied for services rendered is correct. Specialist 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 a specialist office visit provided on August 11, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 31, 2020, to
May 30, 2020.
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says the
enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it
is the provider's responsibility to verify the member's coverage before rendering services and to know proper
billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the home health services provided from March 31, 2020, to
May 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from June 2, 2021, to June 10, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services should be covered in full as you were informed by a plan representative that your copayment would be $335 for the first five days. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services rendered.

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 $335 copayment for Inpatient hospital care. 

You have been asked to pay a $335 copayment per day for two days of inpatient rehabilitation services ($335 x 2 = $670). You have also been asked to pay a $335 copayment per day for six days of inpatient acute care services ($335 x 6 = $2,010). Your total cost-sharing for these services is $2,680. Because you were readmitted into the rehabilitation facility and then admitted back into acute care, the dates were not considered continuous as you were not in the same facility for more than 6 days. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from June 2, 2021, to June 10, 2021.

Your complaint about potentially receiving misinformation from the Plan's representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 is a fall risk and needs to be monitored
due to medication changes. The Plan denied your request. The Plan says the services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 medically necessary. 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 coronary artery bypass grafting
and aortic valve replacement. Her medical conditions 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 documents a
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation
program.
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.