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

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on
September 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that it was medically necessary for
the enrollee to receive the treatment by the doctor and you did not know that the facility failed to get preauthorization. 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 noncontracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336)
provided on September 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided August 24, 2021 to September 7, 2021.
You asked the Plan to pay for the chiropractic service. You say that the doctor's chiropractic and physical therapy treatments have been crucial to your recovery, and you expect more visits with her as you complete your recovery. The Plan denied your request. The Plan says this service is not covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic manipulation of one or more of the extra-spinal regions (98943) provided August 24, 2021 to September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery services to place a Coflex device.
You asked the Plan to pre-approve surgery services to place a Coflex device. You say that this is medically
reasonable and necessary. The Plan denied your request. The Plan says there are not enough studies to show
Coflex device is better than regular spine surgery.
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 surgery services to place a Coflex
device. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the Coflex device remains experimental for spine surgery.
More research is needed before coverage can be approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of surgery services to place a Coflex device have not been met. Therefore, we
decided that the Plan does not have to pre-approve surgery services to place a Coflex device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Modivcare mileage.
You asked the Plan to pre-approve additional mileage. You say that you recently had a kidney transplant, and you are legally blind. You also say that when you enrolled in this Plan, the agent promised you would be covered for this mileage. You add that these checkups are very necessary due to prior infections and this is the only provider in your area. The Plan denied your request. The Plan says you are requesting an additional sixty-six (66) miles for a total of 116 miles. Your benefit only allows 50 miles. You have exceeded your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when The Plan covers up to 60 one-way trips and each one-way trip must not exceed 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles are not covered. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 28, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says payment is not allowed for this claim because the place of service billed does not match other claims for the same date of service.
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 00732 is "Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography (ERCP)."
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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that according to the claims history, the enrollee was an inpatient during dates of service 07/22/2021 - 07/30/2021. In this case, the anesthesia place of service (POS) was documented to be done "On Campus-Outpatient Hospital" (POS 22). The enrollee was documented to have been an inpatient at the time of this procedure. The records do support the coding of this procedure. However, the records do not support the coding of the POS (place of service -22).
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services provided to the enrollee on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis provided on August 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the arthrocentesis. You say that the service was pre-authorized. The Plan denied your request. The Plan says the claim is upheld not because they do no believe it should be paid, but because capitated and delegated medical group is responsible for paying. The Plan says you are not financially responsible.
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 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 arthrocentesis provided on August 25, 2021, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the continuous glucose monitor sensor (A9276) provided on June 18, 2021. We decided that the Plan does not have to waive the coinsurance for the insulin pump (A4224) provided.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the coinsurance has been applied correctly to the items provided.
We decided that the Plan has to waive the coinsurance for the continuous glucose monitor sensor (A9276) provided on June 18, 2021. The Plan contract states that enrollees pay a $0 copayment for Medicare-covered diabetic supplies. Therefore, we decided that the Plan has to waive the coinsurance applied for the continuous glucose monitor sensor (A9276) provided on June 18, 2021.
We also decided that the Plan does not have to waive the coinsurance for the insulin pump (A4224) provided on June 18, 2021. The insulin pump provided in this case is classified as durable medical equipment. Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered durable medical equipment with a total rental or purchase price of $500 or more of the Medicare allowable rate per item per month. The Medicare allowable amount for this item was $594.90. The cost sharing applied was the Medicare allowable amount of $594.90 x 20% coinsurance=$118.98. Therefore, we decided that the Plan does not have to waive the coinsurance applied for the insulin pump (A4224) provided on June 18, 2021.
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: 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 will not make significant gains at a lower level of care. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary approach to rehabilitation care.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for surgical management of an unstable thoracic fracture. Her medical problems are stable. 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.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the endoscopy/cystoscopy procedure (procedure code 52000) you received at an outpatient hospital facility on August 17, 2021.
You asked the Plan to reduce the copayment for the endoscopy/cystoscopy procedure. You say that this service is a diagnostic test, not a surgery. You said that your copayment should only be $20 for a diagnostic test. 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 $325 copayment for outpatient surgery in an outpatient hospital facility.
You have been asked to pay a $325 copayment for the endoscopy/cystoscopy procedure. The Medicare Physician Fee Schedule lists procedure code 52000 as a surgery code, not as a diagnostic test. That is why the endoscopy/cystoscopy procedure falls within the outpatient surgery in an outpatient hospital facility 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 reduce the copayment for the endoscopy/cystoscopy procedure (procedure code 52000) you received at an outpatient hospital facility on August 17, 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 IRF care is medically reasonable and necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 patient was admitted for non-surgical management of pelvic fractures after a fall.
Medical problems are stable. 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 patient has a need for physical and/or occupational therapy, there is
no documentation of a need for an intensive rehabilitation program. In conclusion, 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.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on November 16, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says refractions are
considered a routine exam and provider billed with routine diagnosis codes. The refractions, per our EOC are not covered as this is not covered by Medicare.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on November 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies for the enrollee.
You asked the Plan to pre-approve incontinence supplies. You say that the member cannot manipulate using the toilet. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, 83789, G0480) provided on October 13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that the drug testing was medically necessary and ordered by the patient's physician. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. 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 drug testing (80307, 83789, G0480) provided on October 13, 2021, by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says they will
reassess your progress following the 14 sessions.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
The file shows that 24 physical therapy visits were requested. The Plan approved 14 visits. 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 additional services. Our physician reviewer found that
you have had prior therapy of 17 outpatient physical therapy visits and remains significantly functionally
impaired. The plan approved 14 more visits, which should be more than ample to teach a home exercise
program.
The records do not demonstrate that the unique skills of a professional therapist are required to provide
treatment, that the services can be performed only by a therapist, or under the supervision of a therapist beyond
what was already approved. The outcome of the additional 14 sessions and the need for ongoing skilled
professional therapy beyond what was approved is not clear at this point. The requested services are not part of
a maintenance program, and are not required to establish, design or deliver a program to maintain your current
condition or to prevent/slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does
not have to pre-approve additional physical therapy visits
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 48 additional physical therapy sessions (97161).

You asked the Plan to pre-approve additional physical therapy. You say that the enrollee needs physical therapy The Plan denied your request. The Plan says the submitted documentation from the initial assessment and first therapy visit is not adequate to determine the medical necessity of 48 visits.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The records submitted do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested records do not indicate that the services are part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is needed to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. The documentation indicates a referral for therapy and the knee magnetic resonance imaging (MRI) results. The submitted documentation does not indicate objective physical exam findings of the enrollee's back and knee on physician progress notes. There are no objective prior therapy notes with objective documentation indicating the need for additional therapy. The documentation does not support the request for 48 more therapy sessions.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve the 48 additional physical therapy sessions (97161).