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

 We decided that the Plan does not have to pay for office services provided on August 5, 2021, to August 23, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for office services. You say that you are requesting reconsideration based on medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.   

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 office services provided on August 5, 2021, to August 23, 2021 by an out-of-network (OON) provider.
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. 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 that on review of the available records you have debility and are medically stable.   With your current medical stability and comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehab nursing needs noted in the record. You do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy.  Furthermore, you may not be able to participate fully in therapies and benefit from IRF admission. Your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.  You asked the Plan to pre-approve a Freestyle Libre 2 Sensor. You say that the records provided support the need for the requested item. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 2 Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 Sensor.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-ambulance van service provided on May 5, 2021.  You asked the Plan to pay for the non-ambulance van service. You say that the service should be covered. The Plan denied your request. The Plan says you must obtain prior authorization from the Plan to use out-of-network providers.  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 for medical reasons other than emergencies; Prior authorization is required for services provided by an out-of-network provider.   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. Therefore, we decided that the Plan does not have to pay for the non-ambulance van service provided on May 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the monitoring services provided on August 24, 2020.  You asked the Plan to pay for the services provided. You say that the billed code is the most accurate. The Plan denied your request. The Plan says the code remains not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 95813 is electroencephalogram (EEG) extended monitoring; 61-119 minutes. We find that CPT code 95813 was billed with a place of service 15, indicating a mobile unit. If the mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.  Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the monitoring services provided on August 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services coded S9374 provided from July 7, 2021 to July 9, 2021.  You asked the Plan to pay for the home infusion therapy service. 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 S9374 is home infusion therapy, hydration therapy; one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.   We find that CPT code S9374 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy service have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S9374 provided from July 7, 2021 to July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on October 8, 2021, to October 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a domiciliary or rest home visit. You say that you rely on the facility to obtain this information when they ask you to see patients in their location. You also say that these services were rendered in good faith with expectation of payment. 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 a domiciliary or rest home visit (99336) provided on October 8, 2021, to October 22, 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 the office visits and blood glucose tests provided on March 23, 2021, to April 19, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visits and blood glucose tests. You say that you are appealing these claims. The Plan denied your request. The Plan says the provider is out-of-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 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visits and blood glucose tests provided on March 23, 2021, to April 19, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided September 8, 2021.  You asked the Plan to pay for the periodontal maintenance. You say that you have bad gums and have always needed 4 cleanings a year and it has always been covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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. The Plan covers the periodontal maintenance once every 6 months.   We looked at the file and Medicare rules. The Plan provided documentation showing that periodontal maintenance was previously covered on January 14, 2021and June 3, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the periodontal maintenance has been exceeded. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided September 8, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on July 19, 2021.  You asked the Plan to pay for the hospital discharge day management. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on July 10, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management (99239) provided on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray exam of the knee (73562) provided on August 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an x-ray exam of the knee. You say that the services rendered were determined by the physician's plan of care and the ordering physician's office failed to obtain a referral for the denied services. You also say that as the rendering facility, you should not be penalized. 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 an x-ray exam of the knee (73562) provided on August 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Sanexas therapy and nutripharmaceutical vitamin injection provided on August 31, 2021  You asked the Plan to pay for the Sanexas therapy and nutripharmaceutical vitamin injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that 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 the Sanexas therapy and nutripharmaceutical vitamin injection have not been met. Payment for HCPCS/CPT codes J3411, J3415, J3490, and J7999 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of OK. Therefore, we decided that the Plan does not have to pay for the Sanexas therapy and nutripharmaceutical vitamin injection provided on August 31, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for vision services (92250, 92004) provided on May 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the vision care. You say that the enrollee had serious complaints and the care provided was medically necessary. The enrollee stated that they had Medicare and you did not realize that you were not part the plan's network or that prior authorization was required. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The care provided in this case was not urgent or emergent, nor was it pre-approved or referred by a contracted provider.  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 vision services (92250, 92004) provided on May 17, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) telehealth visit provided on June 21, 2021.  You asked the Plan to waive the copayment for the PCP telehealth visit. You say that it was only a quick follow up call and you thought these were covered in full. 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 $10 copayment for each visit with your PCP, including telehealth visits.     You have been asked to pay a $10 copayment for the PCP telehealth visit. PCP telehealth visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a primary care physician (PCP) telehealth visit provided on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on September 9, 2021, by an OON provider.  You asked the Plan to pay for a domiciliary or rest home visit (99336). You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment and you did not know that the facility failed to get preauthorization for this patient, so you treated this patient anyway. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on September 9, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 871.  You asked the Plan to pay for the inpatient hospital services billed with DRG 871. You say that you would like DRG 871 to be reconsidered as the correctly billed and paid DRG. The Plan denied your request. The Plan says DRG 871 is not supported as the diagnosis of Sepsis, unspecified and Bacterial pneumonia, unspecified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with principal diagnosis code A41.9, defined as Sepsis, unspecified and secondary diagnosis code, J15.9, defined as Bacterial pneumonia, unspecified. 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 inpatient hospital services billed with DRG 871. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found the medical records did not support the billing of Sepsis, unspecified and Bacterial pneumonia, unspecified.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 871.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the risperidone injection provided on February 3, 2021.  You asked the Plan to waive the coinsurance for the risperidone injection. You say that you were informed the coinsurance should not have been charged for this visit. The Plan denied your request. The Plan says the coinsurance applied 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 20% coinsurance for Medicare Part B prescription drugs.    You have been asked to pay $210.60, which is 20% of the allowed amount for the risperidone injection. The allowed amount is $1,053 (20% x $1,053 = $210.60). The risperidone injection falls within the "Medicare Part B prescription drugs" 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 coinsurance for the risperidone injection provided on February 3, 2021.