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

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on August 21, 2019.
You asked the Plan to pay for the drug testing. 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. We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not support evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on August 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 3, 2019. 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on May 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 7, 2019. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 laboratory services rendered on June 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from March 16, 2020 to April 21, 2020.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you were not informed that you would owe a copayment. 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 members must pay a $25 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from March 16, 2020 to April 21, 2020 for a total of 10 visits. Therefore, you are responsible to pay a $25 copayment per each visit. The total amount you owe is: $25 (copayment) x 10 (outpatient rehabilitation services) = $250. You have been asked to the total copayment amount of $250 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services 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 copayments for outpatient rehabilitation services provided from March 16, 2020 to April 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on January 23, 2020. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that you have a $110.26 bill which is over 30% of the cost. 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $125 copayment for the abdominal ultrasound. 
 
You have been asked to pay a $110.26 copayment for the abdominal ultrasound. The abdominal ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 the abdominal ultrasound provided on January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for elbow orthoses (L3761) provided to the enrollee on January 17, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for elbow orthoses (L3761) provided to the enrollee on January 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient clinic visits provided on June 6, 2019 and July 3, 2019. 
 
You asked the Plan to waive the copayments for the outpatient clinic visits. You say that the enrollee has never been charged a facility fee in the past and would like these charges removed. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for each PCP visit.  
 
The enrollee has been asked to pay a $20 copayment for the outpatient clinic visits. The outpatient clinic visits fall within the "Outpatient hospital services" benefit category. 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 copayments for the outpatient clinic visits provided on June 6, 2019 and July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. You asked the Plan to pre-approve SI joint injection. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no documentation that non-invasive, conservative therapy has been attempted. 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 SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found sacroiliac joint injections would not likely be performed unless conservative therapy and non-invasive treatments have failed. There is no documentation that non-invasive or conservative therapy was 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 SI joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services provided January 13 to
January 21, 2020.
You asked the Plan to pre-approve the inpatient mental health services. You say that the services were
medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health services.
Our reviewer says that inpatient level services were not medically necessary. Our physician reviewer found
based upon review the records provided for the admission of this patient does not meet the criteria for
continued acute inpatient mental health treatment for the dates in question of January 13, 2020 forward as this
patient was not shown to be a danger to herself or others. She was not showing any auditory or visual
hallucinations and not showing any threats to safety.
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 inpatient mental health services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient mental health services provided January 13 to January 21,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a long-term acute care hospital (LTACH) is a hospital that has an average inpatient length of stay of greater than 25 days. You can find this rule in the Social Security Act, Section 1886(d)(1)(B)(iv)(I).   
 
The rules say that services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. You can find this rule in the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves. 
 
You asked the Plan to pre-approve the RFA procedure. You say that this treatment is considered necessary to treat the enrollee's knee pain. The Plan denied your request. The Plan says there is not sufficient clinical evidence to support this procedure. 
 
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 the RFA procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure that is the subject of on-going clinical trials and the procedure is not part of evidence-based clinical practice guidelines. Therefore, the request is deemed 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 the RFA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the genicular nerves.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on January 22, 2020.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Upon review, the provider did not provide proof of delivery or a physician's order. Medicare rules require documentation of proof of delivery and
a physician's order be maintain by the durable medical equipment (DME) provider and provided upon request. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on January 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria for transfer
to an LTACH are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the documentation provided the enrollee is currently undergoing treatment
at an acute care hospital (ACH) following coronary bypass surgery. The enrollee was transiently intubated or
ventilated but is no longer intubated or ventilated. There is no evidence that the enrollee requires services that
are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. Medicare criteria for transfer are not met. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long
term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the EKG and office visit services provided
on March 6, 2020.
You asked the Plan to waive the copayments for the EKG and office visit services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you received an EKG and an office visit on the date of service at
issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.
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 $20
copayment for Outpatient diagnostic services and a $45 copayment for specialist visits.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an EKG and a
specialist visit on March 6, 2020. You have been asked to pay a $17.40 copayment for the EKG, which is less
than the contracted $20 copayment. The EKG falls within the Outpatient diagnostic services benefit category.
You have been asked to pay a $45 copayment for the specialist visit. The specialist visit falls within the
Physician/Practitioner services 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 copayments for
the EKG and office visit services provided on March 6, 2020.
Your complaint about the Plan's policies in regards to cost share amounts is not a valid appeal for medical
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not
permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH
are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment
at an acute care hospital (ACH). The enrollee arrived with a tracheotomy. There is no evidence that ventilator
was performed, failed or expected. There is no evidence that the enrollee requires services that are not currently
available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in
transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute
services are required. Medicare coverage criteria are not met. 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 LTACH services
have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care
hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four testing (95999) provided on July 29, 2019.
You asked the Plan to pay for the Train of Four testing. You say that you would like reconsideration because
the services received were medically necessary. The Plan denied your request. The Plan says Medicare does
not make separate payment for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 95999 is not supported in the record. Specifically, the record shows the CPT code
95999 is billed to represent Train of Four testing. Separate payment may not be made for this service because it
is integral to the primary neuromonitoring service. Based on this information, we decided that Medicare rules
for coverage of the Train of Four testing have not been met. Please note, the Plan has stated that you are not
responsible for the payment of this service because the cost is included in the cost of the primary procedure.
Therefore, we decided that the Plan does not have to pay for Train of Four testing (95999) provided on July 29,
2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond July 19, 2020.
You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that the enrollee needs ongoing care. The Plan denied your request. The Plan says the enrollee's mental condition is stable and inpatient services are no longer required.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient psychiatric care. Our reviewer says that the continued inpatient care is not considered reasonable and necessary beyond the date in question. Our physician reviewer found this 45-year-old male was admitted to the acute inpatient psychiatric hospitalization on June 2, 2020 with Schizophrenia Paranoid Type Chronic with Acute Exacerbation. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors although he does have ongoing delusional belief that he is Pamela Anderson or Princess Diana. He is taking his medication and is compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors despite ongoing delusional belief which he has had since teenage years. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question.
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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond July 19, 2020.