Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit provided on October 24, 2019.You asked the Plan to waive the copayment for the podiatry visit. You say that you should not be responsible for the $40 copayment because the pre-op visit should be considered a part of the surgery. 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 $40 copayment for Medicare-covered podiatry services at an in-network specialist's office. You have been asked to pay a $40 copayment for the podiatry visit. The podiatry visit falls within the "Podiatry services" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a pre-operative visit 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 podiatry visit provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forosteogenesis stimulator, electrical, non-invasive, spinal applications (CPT Code E0748) provided to the enrollee on October 2, 2019.You asked the Plan to pay forthe DME. You say that the claim should be paid.The Plan denied your request. The Plan says the following modifier should be used for CPT codes E0747, E0748, and E0760, are class III devices which must be submitted with a KF modifier.ThePlan 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. The rules say that E0747, E0748, and E0760, are class III devices which must besubmitted with a KF modifier.Therefore, we decided that the Plan does not have to pay forosteogenesis stimulator, electrical, non-invasive, spinal applications (CPT Code E0748) provided to the enrollee on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (E1390RR) provided on July 10, 2019, by an in-network provider.You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an oxygen concentrator (E1390RR) provided on July 10, 2019, by an in-network provider. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount is $135.69. The total you owe is $27.13 ($135.69 x 20% = $27.13). 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 oxygen concentrator (E1390RR) provided on July 10, 2019, by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care providedfrom July 5, 2019 through July 6, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from July 5, 2019 through July 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Ambulance Transport (A0427) provided on March 6, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $325 copayment for Ambulance Services. You have been asked to pay a $325 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 copayment foran Ambulance Transport (A0427) provided on March 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo
You asked the Plan to pre-approve Forteo. You say that the enrollee has not tolerated bisphosphonates in the past. The Plan denied your request. The Plan says this medication does not fall under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Forteo
Benefits for Forteo may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require intensive, complex, interdisciplinary therapy in an acute setting.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 physician reviewer found that your current level of function is ambulating 35 feet with minimal assist, minimal assist with supine to sit, minimal assist with sit to stand, minimal assist with transfers, standby assist with balance, moderate assist with lower body dressing, minimal assist with upper body dressing, and minimal assist with toilet transfers. You are currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or acute rehab nursing care. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approve acute 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 services rendered to you on June 4, 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 with a valid CPT code.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 looked at the file and Medicare rules. The file shows that the services at issue were not billed with a valid CPT code. 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 services rendered to you on June 4, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foran implant removal (20680-22) provided on August 9, 2019.You asked the Plan to pay foran implant removal. You say that these services were billed correctly.The Plan denied your request. The Plan says this code is 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 20680 is removal of implant; deep (e.g., buried wire,pin, screw, metal band, nail, rod or plate).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 an implant removal. Our reviewer says that the use of 20680-22 is not supported by the record. Our physician reviewer found the medical records submitted do not include documentation to corroborate Extended Procedural Service of Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate), therefore, the service cannot be verified. Modifier 22 may only be used when the work required to perform a service is substantially greater than normally required. The documentation in the operative note must support the substantial added work, the medial indication for the added work as well as the added complexity of the procedure. These required elements were not present in the operative note of the patient record.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an implant removal have not been met.Therefore, we decided that the Plan does not have to pay foran implant removal (20680-22) provided on August 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on April 26, 2019.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 71045 is the column II code to column I code 36573 and is not eligible for reimbursement.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, we have confirmed that code the chest x-ray has a bundled relationship with code 36573 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on April 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional PT visits.
You asked the Plan to pre-approve the additional PT visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says the additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional PT visits do not meet coverage criteria. Goals established have been achieved. The therapist has had adequate time to safely transition the enrollee to a home exercise program. Additional visits are not reasonable and necessary. The chart notes do not support that the requested services have the inherent complexity and sophistication to require the skills of a licensed professional with specialized training and experience for safe and effective delivery. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve two additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient behavioral health services for the enrollee.You asked the Plan to pre-approvecontinued services. You say that the enrollee would almost certainly decompensate if discharged home.The Plan denied your request. The Plan says the enrollee has no acute symptoms that require 24 hour care.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 continued services. Our physician reviewer found that it did not appear that active treatment was taking place. The services were not reasonably expected or medically necessary to improvethe enrollee's condition, or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 18, 2020, forward and could be treated in a lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient behavioral health services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Arthrocentesis (J1030, 20611RT) provided September 13, 2019.
You asked the Plan to waive the copayment for the procedure. You say that the copayment should be waived because the claim should have been submitted to the VA. The Plan denied your request. The Plan says the correct cost share was applied.
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 outpatient surgical procedures provided by specialists and 20% coinsurance for Part B Drugs You have been asked to pay a $50 copayment and 20% coinsurance for the procedure and the associated Part B drugs. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an Arthrocentesis (J1030, 20611RT) provided September 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on February 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95999 is 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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that the enrollee received train of four testing and there is a more appropriate code for these services. 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 forthe services rendered to the enrollee on February 25, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from August 24, 2019 to September 1, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that you are appealing the denied claim as the services rendered were medically necessary.The Plan denied your request. The Plan says that the enrollee was admitted to hospital from the emergency room for stabilization care without the required authorization from the physician medical group.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 foracute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted on August 24, 2019 for a thoracic spine fracture after a fall. She was evaluated by orthopedics, received pain management and physical and occupational therapy. When medically stable, she was discharged on September 1, 2019. The record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department care and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from August 24, 2019 to September 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forintermittent urinary catheter, with insertion supplies (CPT Code A4353) from August 22, 2019 through August 24, 2019 provided by an in-network provider.You asked the Plan to waive the coinsurance forthe DME. You say that you received a one month supply of catheters after receiving a diagnosis from your urologist; however, you did not feel comfortable with the diagnosis and wanted a second opinion. You state that you did not realize that you had a 15-day time limit to return the supplies and that it's not fair that you have to pay for supplies that you are not using.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received intermittent urinary catheter, with insertion supplies from August 22, 2019 through August 24, 2019 provided by an in-network provider. You are asked to pay 20% coinsurance for the supplies. 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 towaive the coinsurance forintermittent urinary catheter, with insertion supplies (CPT Code A4353) from August 22, 2019 through August 24, 2019 provided by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound compression system application provided on September 25, 2019, October 2, 2019 and October 9, 2019.
You asked the Plan to waive the copayment for the wound compression system application. You say that there was never any invasive procedure performed. The Plan denied your request. The Plan says the copayments 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 $250 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay $204.21, which is less than the standard $250 copayment for each wound compression system application. The total amount you owe is $612.63 ($204.21/visit x 3 visits = $612.63). The wound compression system application falls within the "Outpatient hospital services" benefit category. The wound compression system application is considered 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 wound compression system application provided on September 25, 2019, October 2, 2019 and October 9, 2019.