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

We decided that the Plan does not have to pay for immunofixation electrophoresis (86334) provided on June 13, 2022.

You asked the Plan to pay for immunofixation electrophoresis. You say that these services were provided in an outpatient hospital setting for reading and were reported correctly. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

The Plan must follow Medicare rules. Medicare rules say the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face-to-face service. However, there are two exceptions to this general rule - these are for a service rendered to a patient who is a registered inpatient or an outpatient of a hospital. In these cases, the correct POS code - regardless of where the face-to-face service occurs - is that of the appropriate inpatient POS code (at a minimum POS code 21) or that of the appropriate outpatient hospital POS code (at a minimum POS code 19 or 22).

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of immunofixation electrophoresis have not been met. Specifically, this claim was billed with an outpatient POS code, but the record supports that the enrollee was inpatient status on the date in question. Therefore, the correct POS code to report in this case would be the inpatient POS code. Therefore, we decided that the Plan does not have to pay for immunofixation electrophoresis (86334) provided on June 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of intrauterine. contraceptive device (IUD) provided on November 8, 2021.

You asked the Plan to pay for insertion of IUD. The Plan denied your request. The Plan says insertion of IUD is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that contraceptive devices or medications are not allowed for payment. For this reason the service, 58300, insertion of IUD has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.
We looked at the file and Medicare rules. Medicare does not cover insertion of an IUD. Therefore, we decided that the Plan does not have to pay for insertion of intrauterine. contraceptive device (IUD) provided on November 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low back visits to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve low back visits. You say that you need this service. The Plan denied your 
request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an out-of-network (OON) provider or facility, and this was not an emergency. Therefore, the 
decision is upheld. 
 
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 
low back visits 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 hospital discharge day management (99238) billed for date of service October 29, 2021.

You asked the Plan to pay for hospital discharge day management. You say that the services at issue were billed correctly. The Plan denied your request. The Plan says rules for payment have not been met.

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 99238 is not supported in the medical record. Specifically, the Plan has documented that another unit of this code has been previously paid for the same date of service. The available records do not support two units of the services at issue. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99238) billed for date of service October 29, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) 
rendered by the out-of-network (OON) provider on March 22, 2022. 
 
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 subsequent nursing facility care, 
per day (99309) rendered by the out-of-network (OON) provider on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint interventions (CPT code(s): 64636 and 64635).

You asked the Plan to pre-approve the facet joint interventions. You say that the services are medically necessary. The Plan denied your request. The Plan says you have already had two procedures in this area in the past twelve (12) months.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the facet joint interventions have not been met. You have already undergone two lumbar region radiofrequency sessions in the last rolling 12 months with a different provider: May 11, 2022, (left L4-L5, L5-S1) and May 25, 2022, (right L4-L5, L5-S1). This Plan has reimbursed this provider for these sessions. Therefore, the lumbar region facet joint interventions remain denied as non-covered. Therefore, we decided that the Plan does not have to pre-approve the facet joint interventions (CPT code(s): 64636 and 64635).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on April 20, 2022.

You asked the Plan to waive the copayment for the specialist office visit. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says this cost sharing 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 $20 copayment for Physician/Practitioners services. 

The enrollee has been asked to pay a $20 copayment for the specialist office visit. This item/service falls within the Physician/Practitioners services 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 specialist office visit provided on April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on March 24, 2022.

You asked the Plan to pay for the lab services. You say that these services were performed by a licensed laboratory and were medically necessary. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.

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. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the Plan does not have to pay for lab services provided on March 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need the help with your strength and mobility, 
and you cannot stay in the assisted living facility. The Plan denied your request. The Plan says the criteria for 
admission to a SNF were not met and the enrollee's needs can be met at their assisted living facility with home 
health care services. 
 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does 
not have documented skilled therapy needs. The enrollee is walking household distances. Daily skilled services 
are not required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is medically necessary for the enrollee to receive 
IRF care. The Plan denied your request. The Plan says the enrollee's condition did not meet the Medicare 
guidelines for IRF admission, and the enrollee can safely receive the services they need in a skilled nursing 
facility. 
 
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 enrollee is functioning at a high level despite an acute hospital stay. Intensive 
rehabilitation is not medically necessary. The enrollee does not require frequent physiatry oversight. The IRF is 
not a medical step-down unit and is not available when intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed (E0297), a mattress, foam 
rubber (E0272) and bed side rails (E0305). 
 
You asked the Plan to pre-approve a total electric hospital bed and related supplies. You say that you are 
wheelchair bound and you need to be able to transfer yourself from a bed to a chair or to a commode. You are 
unable to use a manual hospital bed. The Plan denied your request. The Plan says the requested hospital bed is 
mostly for convenience purposes; therefore, it is not covered under Medicare or your health plan. 
 
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 (E0297), a mattress, foam rubber (E0272) and bed side rails (E0305).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) provided on December 20, 2021.

You asked the Plan to pay for ambulance response without transport. You say that you would like these services to be covered. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit. When no transport is provided, there is no payable service.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on December 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without transport (A0998) provided on December 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for disposable drug delivery system, flow rate of 50 ml or greater per hour (A4305) provided June 14, 2021, to June 20, 2021.

You asked the Plan to pay for disposable drug delivery system. You say that you are appealing the denial of this claim. Attached is a letter of explanation showing how codes billed are supported by the doctor's order. The Plan denied your request. The Plan says this service is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of disposable drug delivery system have not been met. Therefore, we decided that the Plan does not have to pay for disposable drug delivery system, flow rate of 50 ml or greater per hour (A4305) provided June 14, 2021, to June 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on June 30, 2022, 
to July 2, 2022. 
 
You asked the Plan to waive the copayment for emergency care. You say that you were expecting coverage for 
your inpatient hospital services. The Plan denied your request. The Plan says this cost sharing 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). Your contract with the Plan clearly says that you must pay $90 
copayment for emergency room.  
 
You have been asked to pay $90 copayment for emergency care. This item/service falls within the emergency 
room 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 emergency care provided on 
June 30, 2022, to July 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on April 8, 2022.

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 separately payable.

The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.

We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on April 8, 2022.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 76705 billed for date of service July 11, 2022.

You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for code 93976.

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 76705 is a column II code to column I code 93976. 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 procedure code 76705 billed for date of service July 11, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided from January 6, 2022, to
March 31, 2022.

You asked the Plan to pay for psychotherapy. The Plan denied your request. The Plan says providers must attempt to consult the attending or primary care physician about the services furnished and document the
consent or declination date to consultations, and the date of consultations in the patient's medical record. There was no documentation of contact in the patient record.

The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy have not been met. Specifically, the record does not include documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required by Medicare rules. Therefore, we decided that the Plan does not have to pay for psychotherapy provided from January 6, 2022, to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 27, 2022.

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 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, pharmacogenetics 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 the laboratory services rendered on March 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on June 6, 2022.

You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says that the enrollee did not meet the criteria to receive out-of-network care without 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 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 a hospital outpatient clinic visit provided on June 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided from December 7, 2020, to October 13, 2021, by a provider that has opted out of Medicare.

You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says payment cannot be made for services performed by a provider that has opted out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the outpatient services provided from December 7, 2020, to October 13, 2021, by a provider that has opted out of Medicare.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 23, 2022.

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. the rules say that Original Medicare is responsible for the costs associated with clinical trials.

We looked at the file and Medicare rules. The file shows that the services at issue were rendered as part of a clinical trial. The claim for these services should be submitted to Original Medicare. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on March 23, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that plans may choose the networks of providers available to enrollees and may require enrollees to obtain authorization before receiving services. You can find this rule at 42 CFR Section 422.112(a) and in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, Medicare Managed Care Manual, Chapter 1, Section 20.2.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.