Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 29, 2019 to June 30, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the admitting physician anticipated greater than 2 midnights of inpatient hospital care. The Plan denied your request. The Plan says the denial of payment for these services is correct, because observation level of care was approved however inpatient level of care was denied.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the records do not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department or observation care) would span at least 2 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 29, 2019 to June 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 10, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says in-network providers must be used when available.
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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies.
You asked the Plan to pre-approve a Dexcom G6 CGM and supplies. You say that you would like to upgrade to a newer CGM. The Plan denied your request. The Plan says you have not had your current CGM for 5 years. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from January 28, 2019 to February 2, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this bill. 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 $395 copayment for each day for days 1-4 for Medicare-covered in-network hospital care. You have been asked to pay a $395 copayment for each day, days 1 to 4 of the inpatient hospital stay. ($395 x 4 = $1,580). The 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 the inpatient hospital stay provided from January 28, 2019 to February 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Beneprotein.
You asked the Plan to pre-approve Beneprotein. You say that the requested item is necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan
does not have to pre-approve Beneprotein.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on December 9,
2019.
You asked the Plan to pay for the dental service. You say that you received a letter saying this service was paid.
The Plan denied your request. The Plan says the service is dental in nature. The Plan also says that since the
service was covered under your dental plan, there is no need for coverage under the medical plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Although the Plan offers a dental benefit in excess of Medicare coverage, the services you are asking the Plan
to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly
supporting your teeth. These are dental services that are not covered or paid for by Medicare. Additionally, the
record shows that this service was paid for by your dental plan. Therefore, we decided that the Plan does not
have to pay for the surgical extraction (D7210) provided on December 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 87086, 87077, 87186, and 81001 provided on August 17, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate claim.
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 87086, 87077, 87186, and 81001 are not supported in the medical record. Specifically, the claim line contains a procedure code that has been previously processed, received, and allowed for the same date of service but with a different place of service/bill type. The claim line contains an evaluation and management code that has been billed with an inappropriate place of treatment. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87086, 87077, 87186, and 81001 provided on August 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on October 18, 2019.
You asked the Plan to pay for a pneumatic compression device and appliances. You say that the equipment was for post-surgical use at home. The Plan denied your request. The Plan says the equipment was used to prevent a thromboembolic event.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on October 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out of network (OON) provider.You asked the Plan to pay for laboratory tests. You say that you disagree with the Plan's denial.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.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 medical services provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis coded 81000 provided on October 17, 2019.
You asked the Plan to pay for the urinalysis. 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 81000 is urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy. We find that CPT code 81000 is not supported in the medical record. Specifically, the documentation does not indicate that urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy was performed. Based on this information, we decided that Medicare rules for coverage of the urinalysis have not been met. Therefore, we decided that the Plan does not have to pay for the urinalysis coded 81000 provided on October 17, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for ConfirmMDx testing provided on September 20, 2019.
You asked the Plan to pay for ConfirmMDx testing. You say that this test is a covered benefit, and you are unable to obtain authorization because specimens for testing are obtained during procedures not performed by you. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this testing was not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that these services would not be covered by the Plan. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this test. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for ConfirmMDx testing provided on September 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extra-spinal manipulation (98943) provided on January 10, 2019 through October 29, 2019.
You asked the Plan to pay for the extra-spinal manipulation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation and all other services ordered by chiropractors are not covered.
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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extra-spinal manipulation (98943) provided on January 10, 2019 through October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 15, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 22, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified. 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 July 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient services. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the plan and the referring physician is also out-of-network with the Plan.
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 medical services provided on November 21, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from April 19, 2019 to April 22, 2019.
You asked the Plan to pay for these services. You say that the services provided were not part of a Hospice
plan of care or related to the enrollee's terminal illness. 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 20, 2019. 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 services provided
from April 19, 2019 to April 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on September 17, 2019.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says that you have no out of network benefits.
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 received from a network optical provider. We looked at the file and the Plan's rules. The file indicates you did not receive these services from a network optical provider. 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 for the vision services provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99153, the moderate
sedation services coded 99152, and the ultrasound guidance services coded 76937 provided on September 10,
2019.
You asked the Plan to pay for the moderate sedation services and the ultrasound guidance services. 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 99153, 99152, and 76937 are not supported in the medical record. Specifically, the
documentation submitted and claim form indicates this procedure was performed in a facility place of service
of 22. Payment for this service is included in payment to the facility and not separately reimbursable for this
provider in this place of service; therefore, code 99153 is not separately payable.
CPT 99152 represents Moderate sedation services provided by the same physician or other qualified health
care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the
presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness
and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. The
documentation submitted did not indicate the presence of an independent trained observer to assist in the
monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot
be verified.
The documentation submitted did not include documentation of ultrasound guidance for vascular access
requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent
real time ultrasound visualization of vascular needle entry, with permanent recording and reporting; therefore,
code 76937 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the moderate sedation services and
the ultrasound guidance services have not been met. Therefore, we decided that the Plan does not have to pay
for the moderate sedation services coded 99153, the moderate sedation services coded 99152, and the
ultrasound guidance services coded 76937 provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services rendered 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 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 office visit provided on August 1, 2019 by an
out of network (OON) provider.