Persius/hicric huggingface dataset:
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medicallynecessary.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 required minimal assistance with transfers and walking 80 feet with a quad cane. You required moderate to maximum assistance for activities of daily living. The documentation supports that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require skilled physical therapy and occupational therapy, but do not require treatment in an intensive rehabilitation therapy program. Your care needs can be met at a lower level of 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on December 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON chiropractic services. You say that these services were medically necessary. The Plan denied your request. The Plan says your OON authorization began on December 12, 2019.
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 chiropractic services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve sinuplasty.
You asked the Plan to pre-approve sinuplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 sinuplasty. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic sinusitis. The enrollee has ongoing sinus congestion for 8 months. The enrollee has tried multiple saline irrigations, antibiotics, and steroids. The enrollee's symptoms include facial pain, sinus pain, vision problems, nasal passage blockage, postnasal drip, tinnitus, snoring, and abnormal sense of smell. Physical exam showed deviation of the nasal septum, inflammation, and thick drainage bilaterally. A CT scan showed scattered sinus mucosal thickening with minimal left maxillary antrum fluids. The documentation supports that the enrollee has a diagnosis, condition, and symptoms that meet criteria for coverage of sinuplasty. The standard of care to treat chronic sinusitis is to start with medical management, and then perform procedures and surgery when the patient does not improve with medical management. Although endoscopic sinus surgery is an option, balloon sinuplasty is also an option and has been proven to treat chronic sinusitis with certain exclusions. Balloon dilation has become an accepted alternative procedure to functional endoscopic sinus surgery (FESS). It can improve drainage of obstructed sinuses. The balloon procedure is less invasive and traumatic than FESS. It has been shown to be effective in improving symptoms and reducing acute exacerbations. Therefore it is medically reasonable for the enrollee to have the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sinuplasty have been met. Therefore, we decided that the Plan has to pre-approve sinuplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve5 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (62323).You asked the Plan to pre-approve5 fractions of SBRT. You say that the services are 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. 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 rulesto determine if the Plan was correct in denying the request to pre-approve 5 fractions of SBRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found for this enrollee, the ASTRO model policy criteria are not met as they have widespread metastatic disease, with multiple prior treatments for bone metastases. RTOG 0631, comparing image-guided radiosurgery or SBRT with external beam radiotherapy in patients with localizedspine metastases, showed no benefit of SBRT over conventional radiotherapy for the treatment of spine metastases with respect to pain control at 3 months or quality of life. Therefore, routine use of SBRT for spine metastases is not indicated. As such, SBRT would not be considered to be furnished in accordance with accepted standards of 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 5 fractions of SBRT have not been met.Therefore, we decided that the Plan does not have to pre-approve5 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (62323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 13, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was a follow up visit for surgery. You say that you shouldn't have to pay. 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 a $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up to a surgical procedure. 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 office visit provided on March 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and insulin. The enrollee had stable vital signs. The enrollee required maximal to total assistance level for functional mobility. The enrollee required varying assistance with activities of daily living. The enrollee remained non-weight bearing to the right lower extremity. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on November 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these services.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 the medical services provided to the enrollee by an out-of-network provider on
November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on January 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network
deficiency for these services.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider
on January 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (70146) provided on February 1, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for this service is included in the payment for another procedure.
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 70146 is not supported in the medical record. Specifically, the record indicates that this x-ray was rendered post-thoracentesis. Separate payment is not made for this radiologic examination. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (70146) provided on February 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan and ultrasound scan provided from July 7, 2018 to August 24, 2018.
You asked the Plan to waive the copayment for diagnostic imaging tests. You say that you were unaware that there would be a copayment for these services. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $60 copayment per visit for diagnostic radiology, including CT scans and ultrasounds. There were 2 visits, resulting in a total copayment obligation of $120. You have been asked to pay $60 copayment per visit for diagnostic imaging tests. Diagnostic imaging 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 a Computed Tomography (CT) scan and ultrasound scan provided from July 7, 2018 to August 24, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care coded 99232 provided on January 9, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are included in another billed code already processed.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99232 is not supported in the medical record. Specifically, this code is for a post-operative visit within the global service period. Payment for this code was included in the payment for the surgical procedure. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care coded 99232 provided on January 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for physical therapy provided from September 4, 2019 through September 25, 2019.
You asked the Plan to waive the coinsurance for physical therapy. You say that your responsibility should be $25 per visit. You say that you satisfied your responsibility with payment of $175. The Plan denied your request. The Plan says the coinsurance 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 25% of the cost for each out-of-network, Medicare covered outpatient rehabilitation service visit.
You have been asked to pay a total of $197.67 for physical therapy.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
September 4, 2019
Physical Therapy
$160
25%
$39.99
September 9, 2019
Physical Therapy
$87.88
25%
$21.97
September 11, 2019
Physical Therapy
$103.27
25%
$25.80
September 16, 2019
Physical Therapy
$103.27
25%
$25.80
September 18, 2019
Physical Therapy
$116.74
25%
$29.16
September 23, 2019
Physical Therapy
$103.27
25%
$25.80
September 25, 2019
Physical Therapy
$116.74
25%
$29.16
TOTAL:
$197.67
Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that you paid $175, leaving a balance of $22.67. 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 coinsurance for physical therapy provided from September 4, 2019 through September 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652). You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not medically necessary. 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 DME have not been met. Medicare rules say that this special device is only covered when the member's swelling involves the chest, trunk and abdomen. Your records do not show that your swelling involves those areas. You do not meet the Medicare rules. Therefore, we decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT Code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 27, 2019. You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service. The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on December 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February 8, 2020. 
 
You asked the Plan to waive the copayment for the laboratory work. You say that you are requesting the copayment to be removed because you have never had to make a payment for lab work. 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 $50 copayment for laboratory services at an in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the laboratory work. 
 
You have been asked to pay a $48.79 copayment for the laboratory work. The laboratory work 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 laboratory work provided on February 8, 2020.   Your complaint about not being informed that changing insurance providers would require payment for labs 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 2, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance. 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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on February 2, 2019.