Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forfitting for contact lens (92310) contact lenses PMMA (V2500) purchased July 29, 2019.You asked the Plan to pay forthe vision services. You say that you are appealing the decision to deny payment for the vision related services.The Plandenied your request. The Plan says the benefit has been exhausted.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, thePlan's coverage rules apply in this case. The Plan covers these services when a $150 allowance once every 24 months to use towards the purchase price of eyewear from a plan optical facility. This benefit is allowed once every 24 months. The records show that this allowance was used July 23, 2018. This benefit is not eligible again until July 23, 2020. We looked at the file and the Plan's rules. The$150 allowance once every 24 months to use towards the purchase price of eyewear from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forfitting for contact lens (92310) contact lenses PMMA (V2500) purchased July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2020) bifocal lens (V2202) purchased on February 19, 2019.
You asked the Plan to pay for the frames and lenses. You say that you had lost your glasses and because of snow and icy weather it was not reasonable or safe for you to go 6 miles to the participating provider and this provider is less than 3 miles from your home. The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the services are rendered by a network provider.
We looked at the file and the Plan's rules. You can use the $150 allowance toward the purchase price of eyewear from a plan optical facility. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2020) bifocal lens (V2202) purchased on February 19, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on February 15, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on February 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 6, 2019 to December 11, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges because you paid less in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment per day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from December 6, 2019 to December 11, 2019. Therefore, you are responsible to pay a $300 copayment for days 1-5 (December 6, 2019 to December 10, 2019). $300 (copayment) x 5 (inpatient days) = $1,500. You have been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided from December 6, 2019 to December 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from September 5, 2019 through October 9, 2019.You asked the Plan to waive the copayment for the SNF stay. You say that you told the provider you could not afford any amount. You say that you were informed the Plan would pay for everything.The Plan denied your request. The Plan says the copayment 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 $0 per day, days 1-20 and $172 per day, days 21-100 for each SNF stay.You have been asked to pay a total of $2,408 for the SNF stay. Date of ServiceSNF Days Number of Days CopaymentMember Liability September 5, 2019-September 24, 20191-2020$0/day$0September 25, 2019-October 9, 201921-3514$172/day$2,408TOTAL:$2,408The SNF stay falls within the "Skilled nursing facility (SNF) care" 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 forthe SNF stay provided from September 5, 2019 through October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornerve conduction studies (95910), needle electromyography (95886) and train of four monitoring (95999) provided onAugust 13, 2019.You asked the Plan to pay forthe neuromonitoring services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95910 is nerve conduction studies; 7-8 studies.The CPT Code Manual definition of code 95886 is  needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).The CPT Code Manual definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure.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 neuromonitoring services. Our reviewer says that CPT code 95910 does not meet criteria for billing or reimbursement consideration. The technical report in the medical records provided does not include documentation on a nerve conduction studies; for 7-8 studies, therefore this service cannot be validated as being performed on August 13,2019. The use of pedical screws, as noted in the medical record, does not meet definition criteria for CPT code 95910. Our reviewer found CPT code 95886 does not meet criteria for billing or reimbursement consideration.  CPT code 95886 is an add-on code and the primary service code has been denied. Additionally, there is no CPT code available for use for Train of Four Monitoring, therefore it is inappropriate to use CPT 95999 for Train of Four Monitoring. 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 neuromonitoring services have not been met.Therefore, we decided that the Plan does not have to pay fornerve conduction studies (95910), needle electromyography (95886) and train of four monitoring (95999) provided on August 13, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for electrocardiogram (EKG) report provided on February 9, 2019.
You asked the Plan to pay for EKG report. You say that this particular service was for emergency care, and the record does not contain any evidence that the same provider billed any other procedures that would include payment for the interpretation of the EKG. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the documentation does not support separate procedures.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. The Plan claims that the documentation submitted does not support separate procedures but has provided no evidence to substantiate this denial. Therefore, we decided that the Plan has to pay for electrocardiogram (EKG) report provided on February 9, 2019.
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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 10, 2019 to November 13, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was necessary due to the enrollee being a high risk patient. The Plan denied your request. The Plan says that this was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was brought to the emergency department on November 10, 2019 with acute mental status changes. She was evaluated and computed tomography of the head demonstrated bifrontal meningioma with mass effect on the corpus callosum and right thalamic lacunar infarct and right frontal infarct. She was treated with IV fluids and IV Ceftriaxone and admitted to telemetry. She continued on IV fluids, IV antibiotics and sliding scale insulin. Her troponins increased to and she was felt to have demand mediated ischemia. Her condition stabilized and improved and she was discharged home on November 13, 2019 when she was considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 10, 2019 to November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided to the enrollee on September 30, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says there was no history of bleeding disorders, clotting, or acute symptoms.
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 testing. Our reviewer says that the testing at issue in this case was not medically reasonable or necessary. Our physician reviewer found there is no evidence that the enrollee had, or was thought to have, a disorder of metabolism. The planned pharmacogenomics testing appears to be a general screening performed on new patients at this clinic. The provided lab report only notes UDT test results, not pharmacogenomics test results. Therefore, there is no evidence to support that the billed service was medically necessary, reasonable or performed. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided to the enrollee on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysneeds can be safely met at lower level of 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 above.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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, HHS, LTC).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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 21, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0648). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a MetropolitanStatistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 21, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided to the enrollee on October 9, 2019.
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 the services were not referred by a network provider or rendered in a participating facility.
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 has network providers available who can provide 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 podiatry services provided to the enrollee on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testopel (S0189).
You asked the Plan to pre-approve Testopel. You say that the medication is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Testopel. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not discuss why pellets are preferred over less invasive topical gel or patches. The documentation does not support the medical necessity for this preparation over other testosterone replacement therapies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have to pre-approve Testopel (S0189).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4K score test provided to the enrollee on March 20, 2019.You asked the Plan to pay for the test. You say that although provider is not currently in-network with the plan, you are requesting that the plan make a clinical gap exception -as provider is currently the only lab who performs the 4Kscore test.The Plan denied your request. The Plan says this test is considered experimental and investigational.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 test. Our reviewer says that the testing at issue in this case is not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s)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 test have not been met.Therefore, we decided that the Plan does not have to pay for the 4K score test provided to the enrollee on March 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) provided on August 17, 2019. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment as the services provided were medically reasonable and necessary for the patient's condition. The Plan denied your request. The Plan says a review of the medical records submitted determined that the billed services were not supported. 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 99291 is critical care services, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported by the documentation in the case file. Specifically, CPT code 99291 is a time-based code. In order to bill CPT code 99291, the documentation must note that 30-74 minutes was spent providing services to the enrollee. The medical records provided in the case file do not note how much time was spent providing these services to the enrollee. As such, the provided documentation does not support the billing of CPT code 99291. Therefore, we decided that the Plan does not have to pay for the critical care, evaluation and management of the critically ill (99291) provided on August 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on January 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for assisted living services. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 has network providers available who can provide 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 assisted living services provided on January 2, 2020 by an out of network (OON) provider.