Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services rendered on February 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 were not billed correctly.  The Plan must follow Medicare rules. The rules say that HH PPS claims must report a 0023 revenue code line.  We looked at the file and Medicare rules. The file shows that the claim was not billed with the required 0023 revenue code. 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 home health services rendered on February 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance (eg, proton) imaging (MRI) and the gadobutrol injection received on April 6, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the magnetic resonance (eg, proton) imaging (MRI) and the gadobutrol injection. You say that you feel the provider should have verified with they were in-network. The Plan denied your request. The Plan says the services received are not a covered benefit.  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 magnetic resonance (eg, proton) imaging (MRI) and the gadobutrol injection received on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that this procedure fills a gap for patients that do not receive adequate relief from conservative methods and do not have instability to indicate that fusion is warranted. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence of its efficacy.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 22, 2021.  You asked the Plan to pay for the therapeutic procedure. 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 supported by the documentation.  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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.   We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that the services were provided by a physical therapist assistant in the home health or hospice setting. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 22, 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 you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While you may require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation doesn't support that you require a power mobility device or wheelchair in the home to accomplish mobility related self-care tasks. You are able to use a rollator or walker in the home and have not had any recent falls.  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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic manipulative treatment (98940) provided on June 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that please review all documentation included and kindly approve your services for payment as these services were medically necessary. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 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 chiropractic manipulative treatment (98940) provided on June 16, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on February 11, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the enrollee was on stretcher upon arrival as the ambulance brought her to her appointment for a Coronavirus vaccine. All side rails were raised, and buckles were latched. The enrollee required a stretcher due to generalized weakness due to a history of obesity, hypertension and edema, lack of ability to stand, walk, and sit for extended periods of time due to osteoarthritis and fibromyalgia. The enrollee was placed in stretcher and stretcher was locked in place via locking mechanism. The enrollee's vitals were taken and recorded, and the enrollee remained stable throughout transport. Upon arrival the enrollee was brought inside and checked in while waiting for her appointment. Signatures were obtained from all appropriate personnel and the ambulance waited for the enrollee during the appointment. The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport on February 11, 2021 was medically reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Cologuard, colorectal cancer screening provided on June 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for Cologuard. You say that you are requesting for reversal of the denial and allow payment of the claim at your contracted rate. 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 non-contracted 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 Cologuard, colorectal cancer screening provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 27, 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 Medicare covers lipid panel testing as cardiovascular screening once every 5 years  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent genetic cardiomyopathy risk panel testing. These genetic panels have not yet been shown to lead to improved outcomes related to testing at this time. The provided records did not show that this enrollee's results would have changed treatment and led to improved care and treatment outcome. Therefore, the enrollee does not meet the criteria for this testing.   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 pay for laboratory services provided to the enrollee on April 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient services provided on January 3, 2021, through May 31, 2021.  You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim submitted includes a missing or invalid claim.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, this claim was billed with CPT code J0604 was billed with an inappropriate modifier. No separate payment can be made for J0604 when it is furnished by an ESRD facility. Therefore, we decided that the Plan does not have to pay for the outpatient services provided on January 3, 2021, through May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing for dermatology services (17110, 69100, 96900, 99204) rendered from June 1, 2021, to July 12, 2021, and the coinsurance for a Medicare Part B Drug provided on June 11, 2021.  You asked the Plan to waive the cost sharing for dermatology services. You say that you feel the services should be covered as the copayments are excessive. The Plan denied your request. The Plan says the copayment applied correctly based on the services rendered.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment for Physician/Practitioner services, including doctor's office visits and a 20% coinsurance for Medicare Part B Drugs.   The enrollee has been asked to pay a $350 copayment for twelve specialist office visits, which is less than $40 per visit. The enrollee is being charged $20.84 for ten of those visits, $40 for two of those visits and a 10% coinsurance ($1.03 for the Medicare Part B Drug provided to the enrollee on June 11, 2021, for a total of $350). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for dermatology services (17110, 69100, 96900, 99204) rendered from June 1, 2021, to July 12, 2021, and the coinsurance for a Medicare Part B Drug (J3301) provided on June 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive or reduce the $25 copayments charged for physical and occupational therapy visits provided from June 28, 2021, to August 23, 2021.  You asked the Plan to waive or reduce these copayments. You say that you cannot afford to pay these copayments. The Plan denied your request. The Plan says these copayments are a contractual obligation.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $25 copayment for each outpatient rehabilitation visit. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive or reduce the $25 copayments charged for physical and occupational therapy visits provided from June 28, 2021, to August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custodial care services (99199) provided February 3, 2021 to June 1, 2021.  You asked the Plan to pay for the custodial care services. You say that in the EOC it states that treatment is covered if the enrollee is unable to care for herself and the enrollee is unable to care for herself. This claim is of the facility where the enrollee is now being treated for Alzheimer's. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. Custodial care is not covered under any circumstance.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the custodial care services (99199) provided February 3, 2021 to June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the services provided to the enrollee on November 23, 2020.  You asked the Plan to waive the deductible. The Plan denied your request. The Plan says the claim processed correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible that the enrollee has to pay out-of-pocket before the Plan will pay its share for the enrollee's covered medical services.   The service you asked the Plan to waive falls within the physician services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to that these services. This cost sharing is a contractual obligation that had not been met at the time the services were received on November 23, 2020. This means the enrollee has been asked to pay the correct amount, $106.62, based on the enrollee's contract with the Plan. Therefore, we decided that the Plan does not have to waive the deductible for the services provided to the enrollee on November 23, 2020.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapy and skilled care services provided from April 21, 2021, to April 30, 2021.  You asked the Plan to pay for the therapy and skilled care services. You say that the enrollee received therapy as well as skilled care unrelated to the hospice diagnosis. 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 April 9, 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 therapy and skilled care services provided from April 21, 2021, to April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure) (77063) provided on October 13, 2020, by an OON provider.  You asked the Plan to pay for the diagnostic services. You say that you are asking for review of the attached medical records and reprocessing of the claims for payment. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted 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 must 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 screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure) (77063) provided on October 13, 2020, by an OON provider.