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

We decided that the Plan does not have to waive the copayment for laboratory tests provided on January 13,
2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you cannot afford the charges.
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 $5
copayment for lab services.
You have been asked to pay a $5 copayment for laboratory tests. Laboratory tests fall 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 laboratory tests provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
February 6, 2020.
You asked the Plan to waive the copayment for the specialist office visit. You say that you were told you would
not be charged a copayment when you get injections in your knee. 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 $30
copayment per specialist office visit.
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls
within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows
you received treatment during your specialist office visit.
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 specialist office visit provided on February 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the drug testing services provided on December 4, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service provided on December 1, 2019.You asked the Plan to pay for the ambulance service. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says that you could have been safely transported by a private vehicle.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. 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 the ambulance service. Our reviewer says that the service was medically necessary. Our physician reviewer found the review indicates that the enrollee,with medical issues,self-referred an ambulance transport for rectum bleeding. In Emergency Department enrollee states having blood in the toilet bowl since Friday but only been passing gas with bowel movements. The review has determined that the patient's presenting symptoms did meet a prudent layperson criteria for emergency care.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 ambulance service have been met.Therefore,we decided that the Plan has to pay for the ambulance service provided on December 1, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for for amyotrophic lateral sclerosis (ALS).
You asked the Plan to pre-approve the testing. You say that a previous physician had noted a similar case, where a patient was found to have a genetic disorder that caused the enrollee's condition. The Plan denied your request. The Plan says there is insufficient scientific evidence to support genetic testing without the documentation of familial history.
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 testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the requested testing would alter the enrollee's disease, guide treatment or affect overall management. Therefore, the requested genetic test is not medically necessary or reasonable. 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 pre-approve genetic testing for for amyotrophic lateral sclerosis (ALS).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 30, 2019 by a non-Plan provider.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 rendered by a non-Plan provider without prior authorization.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 referring provider 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 forthe laboratory services provided on December 30, 2019 by a non-Plan provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99305) provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for OON nursing facility care. You say that the nursing home should have obtained authorization.The Plan denied your request. The Plan says this service 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 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 the nursing facility care (99305) provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that this transfer is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria 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 the enrollee is currently receiving appropriate care to ongoing ventilation weaning and monitoring until stable for discharge to a lower level of care. Based on the successful first weaning attempt, it is unlikely that acute care will be needed for more than 25 days. The enrollee does not require any services at the LTACH that are not already available at the current acute care facility.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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 18, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover these services solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99202) and the therapeutic procedures (97112) provided on February 12, 2020 and February 20, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and the therapeutic procedures (97112) provided on February 12, 2020 and February 20, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve5 hours of home health services.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 enrollee's personal care assistance needs are currently adequately met.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 services do not meet the definition of home health aide services as Section 50.2. The documentation does not reveal clearly that you require skilled nursing services or skilled therapy services to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your needs were primarily custodial in nature and without the need for skilled nursing or skilled therapy services the requested home health aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff.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-approve5 hours of home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99238)
provided on November 24, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says only one hospital
discharge day management service is payable per patient per hospital stay.
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 99238 is hospital discharge day management; 30 minutes
or less.
We find that CPT code 99238 is not supported in the record. Specifically, the record indicates a hospital
discharge day management code was billed, approved and paid for November 23, 2019. Only one hospital
discharge day management service is payable per patient per hospital stay. Based on this information, we
decided that Medicare rules for coverage of the hospital discharge day management services have not been met.
Therefore, we decided that the Plan does not have to pay for hospital discharge day management services
(99238) provided on November 24, 2019.
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 would like reconsideration because a delay in the IRF admission will jeopardize the member's chance for a full recovery. The Plan denied your request. The Plan says the management of the member's condition may be done at a 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 IRF admission is not medically necessary based on the member's current functional status and medical stability. Our physician reviewer found the member does not require an intensive therapy program. The enrollee's rehab needs can be met at a lower intensity setting such as in a Skilled Nursing Facility or in-home with services. 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 waive the cost share for the MRI of the lumbar spine provided on August 13, 2019.You asked the Plan to waive the cost share for the MRI. The Plan denied your request. The Plan says the cost share was applied to your copay 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 $275 copay for outpatient diagnostic tests. The documentation shows that the MRI was approved by the plan. The Medicare-allowed amount for the MRI was $208.17. Because the amount is less than your $275 copay, you were charged the lesser amount. The MRI falls within the outpatient diagnostic tests 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 cost share for the magnetic resonance imaging (MRI) of the lumbar spine provided on August 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF level care is medically necessary.The Plan denied your request. The Plan says the enrollee's needs could be met at a lower level of care, such as a Skilled Nursing Facility.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 the records do not indicate that there are significant, or complex medical or nursing issues that could not be addressed at a Skilled Nursing Facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April25, 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 procedure codes 80156, 80157, 80177, 80201, 80162, 80159, 80173, 82542 and G0483 are 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 80156 is assay of carbamazepine; total. The definition of code 80157 is assay of carbamazepine; free. The definition of code 80177 is levetiracetam drug screen. The definition of code 80201 is assay of topiramate. The definition of code 80162 is assay of digoxin, total. The definition of code80159 is drug assay of clozapine. The definition of code 80173 is assay of haloperidol. The definition of code 82542 is column chromatography of non-drug analyte(s). The definition of code G0483 is definitive drug testing, 22 or more drug classes.We find that CPT codes 80156, 80157, 80177, 80201, 80162, 80159, 80173, 82542 and G0483 are not supported in the medical record. Specifically, there is no documentation of an assay of carbamazepine; total to support code 80156. There is no documentation of an assay of carbamazepine; free to support code 80157. There is no documentation of a levetiracetam drug screen to support code 80177. There is no documentation of assay of to piramate to support code 80201. There is no documentation of an assay of digoxin, total to support code 80162. There is no documentation of drug assay of clozapine to support code 80159. There is no documentation of assay of haloperidol to support code 80173. There is no documentation of column chromatography to support code 82542. There is no documentation of definitive drug testing of 22 or more classes to support code G0483. 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 April 25, 2019
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve eyelid/brow surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says that the records provided do not show vision tests indicating certain problems with the
enrollee's sight.
The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically
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 the surgery. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found brow ptosis repair is medically necessary in this case based on the functional complaints, photos, visual
field tests, and physical exam. In this situation, it is clear that you have dermatochalasis and brow ptosis as
evidenced by photographs. The records demonstrate functional complaints and examination findings and visual
field defects that are consistent. The health plan argument that lack of MRD documentation is not supported by
the LCD requirements for coverage. The exam, visual fields, history and photographs are compelling evidence
of functional disability and do meet the LCD criteria.
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 surgery have been met. Therefore, we decided that the Plan has to preapprove
eyelid/brow surgery.
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.