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

We decided that the Plan does not have to pay for laboratory testing provided on June 17, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab tests. You say that you do not have information on the enrollee's insurance requirements, limitations, or conditions. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with 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 laboratory testing provided on June 17, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87496 provided on November 6, 2020.

You asked the Plan to pay for the infectious agent detection by nucleic acid services. 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 supported by the documentation.

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 87496 is infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique.

We find that CPT code 87496 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 13. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87496 provided on November 6, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Impella, insertion of ventricular assist device (VAD), represented
by CPT code 33990.
You asked the Plan to pre-approve Impella, insertion of ventricular assist device (VAD), represented by CPT
code 33990. You say that the requested Impella, insertion of ventricular assist device (VAD) is medically
necessary. The Plan denied your request. The Plan says that the requested Impella, insertion of ventricular
assist device (VAD) is not medically necessary.
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 Impella, insertion of ventricular assist
device (VAD), represented by CPT code 33990. Our reviewer says that the requested Impella, insertion of
ventricular assist device (VAD) is medically necessary. Our physician reviewer found the Impella device in
this instance is not being used for post cardiotomy or Class IV heart failure support but rather as transient
ventricular support in a planned very high risk PCI procedure on the only remaining patent saphenous vein
graft which is supplying nearly all the circulation of this enrollee's heart. As such it would be a medically
reasonable and necessary use of the technology for transient cardiac support during the PCI procedure (1),
especially if there is a distinct concern of distal vein graft embolization, which is a much higher possibility,
given the advanced age (17 years) of this bypass graft. The use of the Impella LV assist device in this situation
would therefore meet the applicable Section 1862 (a) 1(A) medically reasonableness and necessity criteria in
this specific high-risk clinical situation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Impella, insertion of ventricular assist device (VAD), represented by CPT code
33990 have been met. Therefore, we decided that the Plan has to pre-approve Impella, insertion of ventricular
assist device (VAD), represented by CPT code 33990.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without contrast material (72148).

You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the MRI is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an MRI at this time.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our reviewer says that an MRI is not medically necessary. Our physician reviewer found that there is no specific delineation of any change in the enrollee's physical findings or symptoms since the referenced MRI of the lumbar spine of November 25, 2020. There is no report of that scan in the records. Plain x-rays including flexion-extension views show no instability and no appreciable change since that prior MRI. There is mention in the notes of considering a course of physical therapy however that has not been done yet. Due to her neurological normal exam and lack of red flags, no documented change in symptoms since her MRI of November 25, 20/20 and her lack of instability on plain films, the medical necessity of the requested repeat MRI of the lumbar spine has not been established in the records provided. 

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 MRI of the lumbar spine have not been met.

Therefore, we decided that the Plan does not have to pre-approve a Magnetic resonance (eg, proton) imaging (MRI), spinal canal and contents, lumbar; without contrast material (72148).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve replacement BiPAP (Bilevel Positive Airway Pressure) E0470 that
was voluntarily recalled by Phillips Respironics.

You asked the Plan to pre-approve the BiPaP. You say that you require this device. The Plan denied your
request. The Plan says that any equipment less than five years old must be documented to be irreparably
damaged or lost.

The Plan must follow Medicare rules. Medicare rules say that equipment which the enrollee owns or is a
capped rental item may be replaced in cases of loss or irreparable damage. The BiPap, through no fault of the
enrollee's has become unusable. The recall notice recommends immediate discontinuation of use with highest
level of severity. The company also reports shortages on supplies for fixing and replacing the BiPaP machines
affected, so in that sense, it is not repairable or replaceable. The enrollee requires the device.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the BiPaP have been met. Therefore, we decided that the Plan has to pre-approve replacement
BiPAP (Bilevel Positive Airway Pressure) E0470 that was voluntarily recalled by Phillips Respironics.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stem cell harvesting for transplantation procedure (38206).
You asked the Plan to pre-approve stem cell harvesting. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment has not been proven effective for the enrollee's condition.
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 stem cell harvesting. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that stem cell harvesting/bone marrow aspirate has not demonstrated to be a superior technique in allowing for healing of an arthrodesis to occur. The enrollee does not exhibit other medical conditions that would reduce healing capacity. Bone marrow aspirate application is not yet accepted as a standard practice in arthrodesis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of stem cell harvesting have not been met. Therefore, we decided that the Plan does not have to pre-approve a stem cell harvesting for transplantation procedure (38206).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent screening (87150, 87482, 87500, 87640, 87798, 87799) provided on April 23, 2021.

You asked the Plan to pay for infectious agent screening. You say that this was ordered by the physician. The Plan denied your request. The Plan says this is not covered for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, infectious agent screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for infectious agent screening (87150, 87482, 87500, 87640, 87798, 87799) provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the wrist hand finger orthosis (WHFO) provided on December 28, 2020.
You asked the Plan to pay for the WHFO. You say that this brace is different and should be paid for by the Plan. The Plan denied your request. The Plan says that that the billed item has been reported and paid with the previous five years.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any evidence that you have received and had covered a WHFO within the last five years. Without documentation from the Plan confirming you have already had a WHFO covered by the Plan, we are unable to substantiate the Plan's denial rationale. Therefore, we decided that the Plan has to pay for the wrist hand finger orthosis (WHFO) provided on December 28, 2020.
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 physician services (99153) provided March 5, 2021

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 

We find that CPT code 99153 is not supported in the medical record. Specifically, the CPT code billed has a professional component / technical component value of 3 and is not eligible for payment when provided to a hospital patient. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99153) provided March 5, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ground ambulance transport services provided on April 19, 2021.

You asked the Plan to waive the copayment for ground ambulance transport services. You say that you are receiving bills you cannot afford for services that did not treat your issues. You say you should not have been transported by ambulance. 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 $200 copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.

You have been asked to pay $200 copayment for ground ambulance transport services. Ground ambulance transport services fall within the Ambulance 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 ground ambulance transport services provided on April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy rendered on November 25, 2020 to
December 2, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that infrared therapy is not covered.
We looked at the file and Medicare rules. The services at issue are infrared therapy. These services are not
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the infrared therapy
rendered on November 25, 2020 to December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve dermatology services. You say that you would like the Plan to approve these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network physicians available to provide these services.

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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve dermatology services to be provided 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 critical care services rendered from May 27, 2020 to May 28, 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 procedure code 99291 is 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care spent on the enrollee for the dates of service at issue. 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 the critical care services rendered from May 27, 2020 to May 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 3, 2021 by an out-ofnetwork
provider.

You asked the Plan to pay for the office visit (99215). You say that the Plan should pay this claim. The Plan
denied your request. The Plan says you did not request 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 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 March 3, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endocrinology office services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office services. You say that you were advised to see this provider. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network endocrinology specialist.

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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve endocrinology office services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.

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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting
from March 6, 2021, to March 26, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were not allowed to take your
personal medications while you were in the hospital. The Plan denied your request.
The Plan says the drugs that you received are considered self-administered. The Plan says self-administered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received
are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs
provided in an outpatient setting from March 6, 2021, to March 26, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.