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

We decided that the Plan does not have to pay for the surgical pathology services coded 88307 provided on September 24, 2020.
You asked the Plan to pay for the surgical pathology 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 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, the CPT Code Manual definition of code [Enter billing code at issue (e.g. 43856, K0002, etc.)] is Level V - Surgical pathology, gross and microscopic examination Adrenal, resection Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation
Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta, third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) - biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse. We find that CPT code 88307 is not supported in the medical record. Specifically, the documentation supports two units of this code which were previously approved and paid by the Plan. There is no additional documentation supporting additional studies. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88307 provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 the enrollee does require physical therapy and occupational therapy services but
based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy
program. Care at the skilled nursing facility level appears to be appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lipid panel testing provided on July 19, 2021.

You asked the Plan to pay for the testing services. You say that those who have heart disease, or a family history of high cholesterol need to get their cholesterol checked more often. The Plan denied your request. The Plan says limited services were exceeded.

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 file shows that you received lipid panel testing on July 19, 2021. You last received this testing on August 2, 2019. We looked at the file and the rules. Your plan only covers this testing once every five years. Based on this information, we decided that the rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lipid panel testing provided on July 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 physician services provided on April 28, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power seating system motors.
You asked the Plan to pre-approve an electronic connection between wheelchair controller and 2 or more power seating system motors. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are met. 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 electronic connection between wheelchair controller and 2 or more power seating system motors. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504) for the expanded controller components (E2377, E2313, E2311). Records indicate you are independent with upper and lower body dressing and has bilateral 4/5 upper extremity strength. Records indicate you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection between wheelchair controller and 2 or more power seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and 2 or more power seating system motors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type with a non-invasive interface.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says there must be sufficient detailed documentation in the medical record to justify the treatment selected.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The record indicates that the enrollee improved significantly on bilateral positive airway pressure (BiPAP). The elements of the coverage criteria are not satisfied. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type with a non-invasive interface.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility services provided from April 1, 2020, through April 7, 2020 billed with code GAGD1.
You asked the Plan to pay for the SNF care as billed. You say that it is felt this was billed correctly. The Plan denied your request. The Plan says the removal of the two unsupported diagnosese changes the HIPPS code for this SNF stay.
The Plan follows Medicare rules. Medicare rules say that SNF payment is made based on the HIPPS code which is calculated based on the information documented in the MDS assessment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF care as billed. Our reviewer says that the documentation does not support inclusion of asthma/COPD or malnutrition as active diagnoses for this SNF stay. Our physician reviewer found the member is a 91-year-old female with a past medical history including diabetes mellitus, congestive heart disease and chronic lung disease including asthma and pulmonary hypertension who was admitted to an acute hospital due to a left talus chip fracture and pneumonia. She stabilized and was discharged to a skilled nursing facility for rehab services. The documentation indicates that her respiratory status was stable and without exacerbation. The documentation supports that asthma/COPD and malnutrition were not the active diagnoses for the stay in the skilled nursing facility from 4/1/2020 through 4/7/2020. We looked at this physician's review, the file, and Medicare rules. Since the case-mix groups are changed by the removal of these diagnoses, the HIPPS code billed for this SNF stay is not supported. Based on this information, we decided that Medicare rules for coverage of the SNF care as billed have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility services provided from April 1, 2020, through April 7, 2020 billed with code GAGD1.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 26, 2021.

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 the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2740) for tooth #12.
You asked the Plan to pre-approve the crown (D2740). The Plan denied your request. The Plan says this service is only allowed one time every 60 months.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, there is also a maximum benefit of one crown per tooth every 60 months. The Plan paid for the crown (D2751) for tooth #12 provided on August 20, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on April 9, 2021.

You asked the Plan to pay for an eye exam. The Plan denied your request. The Plan says services obtained from vendors outside of the Plan's network are not covered.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when obtained from a provider in the Plan's vision vendor network. 

We looked at the file and the Plan's rules. The file shows that the eye exam was not obtained from a provider in the Plan's vision vendor network. Based on this information, we decided that the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on April 9, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 29, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that this bill is a financial hardship for you. The Plan denied your request. The Plan says you were charged this copayment 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 a $90 copayment for emergency room visits. 

You have been asked to pay a $90 copayment for the ER visit. 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 the emergency room (ER) visit you had on May 29, 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.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70450) provided August 6, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 70450 is a column II code to column I code 70496. 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 radiology services (70450) provided August 6, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99308) provided on April 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for nursing facility care. You say that the provider is contracted with the facility. The Plan denied your request. The Plan says this was not authorized.

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 nursing facility care (99308) provided on April 28, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new pair of eyeglasses for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the new frame and lenses are above the $200 allowed annual benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a maximum annual benefit of $200. The file shows that the benefit for 2021 has already been used, and the requested services cost more than $200. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a new pair of eyeglasses for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the office visit you had with an out-of-network pain management specialist on February 12, 2021.

You asked the Plan to reduce the copayment for the out-of-network specialist visit. You say that you paid a $20 copayment to this provider and you are now being billed $20 more. The Plan denied your request. The Plan says you were charged this copayment 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 a $45 copayment for out-of-network specialist visits. 

You have been asked to pay a $45 copayment for the out-of-network specialist visit. 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 reduce the copayment for the office visit you had with an out-of-network pain management specialist on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injections provided on June 28, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for injections. You say that the beneficiary was unaware an authorization was needed. The Plan denied your request. The Plan says the services were provided out-of-network and were not 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 injections provided on June 28, 2021, 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 pneumatic compression device with garments to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a pneumatic compression device with garments. You say that in-network suppliers are not able to provide this item. The Plan denied your request. The Plan says this item can be supplied in-network.

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 a network provider 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 a pneumatic compression device with garments to be provided by an out-of-network (OON) provider.