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

We decided that the Plan does not have to pay for transportation of portable X-Ray equipment (code R0070) provided on March 31, 2021.

You asked the Plan to pay for portable X-Ray. You say that this testing was required to be provided on-site, and there were no contracted providers that could have performed it. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Place of Service (POS) code billed on this claim is not appropriate.

The Plan must follow Medicare rules. Medicare rules say that Place of Service (POS) code 32 should be used with services for beneficiaries in a noncovered nursing facility stay. 

We looked at the file and Medicare rules. We looked at the file and Medicare rules. The records show that the claim for the services in dispute was billed with a POS code of 31. The record indicates that the member was not in a Part A covered SNF stay on the billed date of service. There is a more appropriate POS code for the billed services. Based on this information, we decided that Medicare rules for coverage of portable X-Ray have not been met. Therefore, we decided that the Plan does not have to pay for transportation of portable X-Ray equipment (code R0070) provided on March 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted ambulance service coded A0999 provided on January 3, 2021.
You asked the Plan to pay for the unlisted ambulance 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 A0999 is unlisted ambulance service. We find that CPT code A0999 is not supported in the medical record. Specifically, this code has a status code of "X". A status code of X means that this code is a statutory exclusion. These codes represent an item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No payment may be made under the physician fee schedule. Based on this information, we decided that Medicare rules for coverage of the unlisted ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted ambulance service coded A0999 provided on January 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 13, 2021.
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on April 13, 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 enrollee needs to fully recover and if he waits to start, he will go backwards in his recovery. The Plan denied your request. The Plan says based on Medicare guidelines, the request for IRF services does not meet the requirements for approval.
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 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.
Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head rendered on January 9, 2021.

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 payable as billed.

The Plan must follow Medicare rules. The rules say that modifier -76 is used to indicate that the same physician repeated a procedure or service in a separate operative session on the same day. Modifier -XS is utilized in place of -59 to represent a separate and distinct service. 

We looked at the file and Medicare rules. Procedure code 70544 (MRA head) was billed with modifier -76 and -XS. Modifier -76 represents a repeat service and modifier -XS is for a separate and distinct service. These modifiers are not able to be billed together. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head rendered on January 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 17, 2021.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479.

Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and topical application of fluoride varnish (D1208) provided on April 14, 2021.

You asked the Plan to pay for the dental services. You say that you do not understand when this service was provided to you last time. You also say that you have not received this service by this provider before. The Plan denied your request. The Plan says 1 complete set or panoramic x-ray is covered every 5 years. the Plan says that the frequency limit has been exceeded. The Plan also says that the topical application of fluoride varnish is not listed as a covered 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.

Though the Plan offers a dental benefit in excess of Medicare coverage and panoramic x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received from this provider on September 20, 2020. Additionally, topical application of fluoride varnish is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and topical application of fluoride varnish (D1208) provided on April 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services 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 information does not support the need for a home health aide to make visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has had several strokes resulting in left side weakness. The enrollee requires assistance for mobility and ADLs. There is no evidence of a new injury or illness. The requested services appear to be custodial, rather than part of a treatment program. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology and cytopathology services rendered on March 3, 2021.

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 claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology and cytopathology services rendered on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on February 15, 2021.

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 were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with Place of Service (POS) code 21. 

We looked at the file and Medicare rules. The services at issue were billed with POS code 21 for inpatient services; however, the records show that the services were performed while the enrollee was outpatient.

Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on February 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomographic (CT) angiography represented by code 74175 provided on May 8, 2021.
You asked the Plan to pay for code 74175. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the Plan does not have to pay for the computed tomographic (CT) angiography represented by code 74175 provided on May 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says you are medically stable with no skilled nursing needs.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you have been stabilized medically and have been discharged from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. The intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. There are no acute exacerbations of chronic medical problems. You have been educated regarding the use of a wheelchair and require custodial assistance. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (83036, 82747, 82306, 82728) provided on May 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for OON laboratory services. You say that the ordering physician should have obtained authorization. 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 laboratory services (83036, 82747, 82306, 82728) provided on May 27, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract services provided on February 2, 2021 to March 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the cataract services. You say that the services you received were urgent. The Plan denied your request. The Plan says the services received was non-emergent and non-urgent.
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 cataract services provided on February 2, 2021 to March 30, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on September 1, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on September 1, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for testing services received outside of the United States on April 6, 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 that this service is not a covered benefit of the plan.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. The plan does not limit the out of country urgent care benefit by saying that coronavirus (COVID-19) testing is not covered in the Evidence of Coverage. This testing can be considered urgent as it was needed to return the United States. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for testing services received outside of the United States on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right ankle arthroplasty.
You asked the Plan to pre-approve right ankle arthroplasty. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 right ankle arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures, to include recent physical therapy. In addition, there are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this current clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for right ankle arthroplasty is not medically reasonable or 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 right ankle arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve right ankle arthroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider from March 28, 2021, to March 31, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available 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 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 services at issue in this appeal. 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 the services provided to the enrollee by an out-of-network provider from March 28, 2021, to March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pulmonary risk screening (81302, 81330, 81345, 81407, 81408, 81479) provided on December 9, 2020.

You asked the Plan to pay for pulmonary risk screening. You say that this should be covered. The Plan denied your request. The Plan says an order is not included in the file.

The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. There is not a physician order included in the submitted records. Based on this information, we decided that Medicare rules for coverage of pulmonary risk screening have not been met. Therefore, we decided that the Plan does not have to pay for pulmonary risk screening (81302, 81330, 81345, 81407, 81408, 81479) provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus vaccine you received on May 12, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not covered under your Part B plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the tetanus vaccine you received on May 12, 2021.