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

We decided that the Plan does not have to pay forthe office visit provided by an out-of-network provider.You asked the Plan to pay forthe office visit. You say that the enrollee was referred for a visit.The Plan denied your request. The Plan says this provider is not a network provider 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 forthe office visit provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 27, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because you
are an ancillary lab and do not have face-to-face contact with the member. The Plan denied your request. The
Plan says there i no authorization on file for the services in question.
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 August 27, 2020
by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery: right L5-S1 transforaminal lumbar interbody fusion at L5-S1 and left L2-5 laminectomy (CPT Codes: 22633, 63047, 63030, 63035) for the enrollee.
You asked the Plan to pre-approve the requested surgery. You say that the services are necessary, and the surgery scheduled on January 21, 2021. The Plan denied your request. The Plan says their policy requires there be clinical documentation that three (3) months of conservative therapy within the last six (6) months (such as physical therapy or injections) has failed to adequately treat the patient's symptoms and that there are physical findings of nerve root compression (such as weakness) on exam from the patient's physician. The Plan states the submitted documentation does not indicate the patient has completed conservative treatment in the last 6 months and there were no findings of nerve root compression on exam from their physician.
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 back surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found when symptoms derived from spinal and foraminal stenosis interfere with activities of daily living and are refractory to conservative treatment, surgical management may be considered. The documentation in this case is insufficient to demonstrate that a right L5-S1 transforaminal lumbar interbody fusion at L5-S1 and left L2-5 laminectomy are medically reasonable and necessary for the enrollee in this case. Documentation of interference with activities of daily living are lacking, and there is no documentation of failure of conservative management. 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 back surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve back surgery: right L5-S1 transforaminal lumbar interbody fusion at L5-S1 and left L2-5 laminectomy (CPT Codes: 22633, 63047, 63030, 63035) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.You asked the Plan to pre-approve the hearing aids. You say that your hearing aids are not working well and would like new ones. The Plan denied your request. The Plan says the clinical documents did not include updated audiology report, signed ENT examination or signed prescription for hearing aids. Therefore, the request does not meet criteria and is denied.The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify pre-approval for the hearing aids. Based on this information, we decided that Medicare rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded 76770 provided on August 20, 2020.
You asked the Plan to pay for the ultrasound 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. In this case, the CPT Code Manual definition of code 76770 is ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete. We find that CPT code 76770 is not supported in the medical record. Specifically, the documentation supports one unit of this service, which was previously approved and paid. There is no additional documentation supporting an additional study which was billed. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services coded 76770 provided on August 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea SNF admission.You asked the Plan to pre-approvethe SNF admission. You say that a SNF admission has been recommended by all of the enrollee's providers at the facility.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for admission to a SNF.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 the SNF admission. Our reviewer says that the enrollee doesnot meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvea SNF admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 21, 2019.You asked the Plan to pay forthe services provided. You say that you depend on the facility for timely notification of the enrollee's health insurance coverage.The Plan denied your request. The Plan says the claim was received past the allowed timeframe.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the services provided was not filed until August 31, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe medical services provided on February 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency services provided.

You asked the Plan to waive the copay for the services provided. You say that you were taken to the wrong hospital.The Plan denied your request. The Plan says the claim processed 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 $120 copay for emergency care. 

You have been asked to pay a $120 copay for the services provided. The services fall within the emergency 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 copay for the emergency services provided.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says you did well during your hospital stay, and the doctor identified no skilled nursing needs.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you require skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapisdt is not required to safely and effectively provide medically necessary and reasonable treatment. You do not require the services on an inpatient basis, in a skilled nursing facility setting. Services in the home with home health services or in a long-term care facility on a part time basis appear appropriate in this case.
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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co payments for ambulance services and an inpatient hospital stay.

You asked the Plan to waive the co payments for ambulance services and an inpatient hospital stay. You say that this was an emergency situation and you disagree with 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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 co payment for ambulance services.Your contract with the Plan also clearly says that you must pay a $290 co payment for days 1-7 for inpatient hospital care. 

You received ambulance services. Therefore, you are responsible to pay the $275 co payment. 

You received ambulance services. Therefore, you are responsible to pay the $275 co payment.You had an inpatient hospital stay. Therefore, you are responsible to pay a $290 co payment for days 1-2. $290 (co payment) x 2 (inpatient days) = $580. 

The total amount you owe is: $1,130

You have been asked to pay the total co payment amount of $1,130 for ambulance services and an inpatient hospital stay. Ambulance services fall within the ambulance services benefit category. An 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 co payments for ambulance services and an inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe injection services provided on May 27, 2020.You asked the Plan to pay forthe injection 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 medically necessary.The Plan follows Medicare rules. Medicare rules say that injection services are only covered for certain indications.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 injection services. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee had injured his right shoulder after a rotator cuff surgery. The bill submitted was for facet joint injections which are not documented at all and there is no documentation of conservative therapy prior to the proposed injection. Therefore, the enrollee did not meet criteria for the services billed.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 injection services have not been met. Therefore, we decided that the Plan does not have to pay forthe injection services provided on May 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on August 10, 2020.
You asked the Plan to pay for the comprehensive oral evaluation. You say that a comprehensive exam is
required for all new patients, so you had no choice but to get another. You say that the Plan should cover the
fee. The Plan denied your request. The Plan says a comprehensive exam is covered once every three years.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit
of one comprehensive oral evaluation every three years. The Plan paid for a comprehensive oral evaluation
provided on September 30, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe office visit (99202) and extremity study (93970) provided on August 20, 2020.You asked the Plan to pay forthe office visit and extremity study. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this claim was not billed correctly.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.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the denial reason for CPT code 99202 references two diagnosis codes which were not billed on the claim. The submitted claim includes an appropriate diagnosis code. Additionally, the Plan cites a retired LCD for the denial of CPT code 93970. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay forthe office visit (99202) and extremity study (93970) provided on August 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on July
18, 2020.
You asked the Plan to waive the copayment for emergency room visit. You say that you did not really need to
go to the emergency room, but the police told you to. The Plan denied your request. The Plan says the
copayment amount you are being charged is 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 $90
copayment for Emergency Care.
You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the
Emergency 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 an emergency room
visit provided on July 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient office visit (99214) provided August 6, 2020.You asked the Plan to waive the copayment forthe office visit. You say that at this time to pay your doctor office $90 back at once hurts you due to loss of your part through work due to COVID.The Plan denied your request. The Plan says this claim was processed and the correct copayment applied per the Evidence of Coverage.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 $45 copayment for in-network specialist's office. You have been asked to pay $45 copayment for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits 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 foroutpatient office visit (99214) provided August 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by a participating provider on September 8, 2020.You asked the Planto waive the copayment for a diagnostic mammogram. You say that you had cancer and now you have yearly mammograms. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $40 copayment for outpatient diagnostic tests/basic imaging service. You have been asked to pay a $40 copayment for a diagnostic mammogram. The mammogram that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A diagnostic mammogram falls within the outpatient diagnostic tests/basic imaging service 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 diagnostic mammogram provided by a participating provider on September 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.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 theLTACH services. Our reviewer says that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with severe leg infection and underwent a left below knee amputation. He developed COVID pneumonia. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services.