Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for alcohol detoxification services (H0010) provided from September 17, 2019 to September 23, 2019.
You asked the Plan to pay for alcohol detoxification services. You say that you expected to be reimbursed for these services. The Plan denied your request. The Plan says records have not been submitted to support these charges.
The Plan must follow Medicare rules. Medicare rules say that [or Medicare to consider coverage and payment for any item or service, the information submitted must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of alcohol detoxification services have not been met. Specifically, no medical records have been submitted to show that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for alcohol detoxification services (H0010) provided from September 17, 2019 to September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab work provided on August 20, 2019 by out of network provider. You asked the Plan to pay for outpatient lab work. You say that you would this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 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 foroutpatient lab work provided on August 20, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care with weakness and trouble getting around.Based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee is already ambulating more than 100 feet. The enrollee's 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from September 10, 2019 through September 12, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were admitted due to the dropped clips from the prior procedure. 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 shows that you received inpatient hospital care from September 10, 2019 through September 12, 2019. You were asked to pay a $285 copayment per day from September 10, 2019 through September 11, 2019, days 1-2 of your inpatient hospital care. You were discharged on September 12, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $285 copayment per day required for days 1-7 for each inpatient stay. 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 inpatient hospital care provided from September 10, 2019 through September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a chest wall respiratory sensor (Inspire
procedure).
You asked the Plan to pre-approve Inspire procedure. You say that this denial is preventing your access to
valuable medical treatment that can improve your quality of life. The Plan denied your request. The Plan says
the denial of authorization for this service is correct, because this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the Inspire procedure with procedure code 0466T
is not considered medically reasonable and necessary at this time and is not covered by Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Inspire procedure have not been met. Therefore, we decided that the Plan does not have to preapprove
insertion of a chest wall respiratory sensor (Inspire procedure).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from September 24, 2019 through September 29, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. 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 shows that you received inpatient hospital care from September 24, 2019 through September 29, 2019. You were asked to pay a $250 copayment per day from September 24, 2019 through September 28, 2019, days 1-5 of your inpatient hospital care. You were discharged on September 29, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-5. 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 inpatient hospital care provided from September 24, 2019 through September 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the custom orthotic brace provided on August 30, 2019.
You asked the Plan to waive the coinsurance for the custom orthotic brace. You say that the custom orthotic brace does not fit. 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). The servicing provider confirmed that you went in for measurements and a digital scan so that the brace could be custom fitted. In addition, the supplier provided us with a copy of a consent form that you signed. Therefore, you are asked to pay 20% coinsurance for the orthosis. 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 the custom orthotic brace provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the anesthesia services provided on September 4, 2019.
You asked the Plan to waive the coinsurance for the anesthesia services. You say that you were never told there would be separate charges for this procedure. You say you refuse to pay 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 50% coinsurance for provider and professional services at an outpatient hospital or ambulatory surgical center. You have been asked to pay $51.95 which is 50% of the allowed amount for the anesthesia services. The allowed amount is $103.91. ($103.91 x 50% = $51.95). The anesthesia services fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the anesthesia services were billed separately by an out-of-network provider.
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 the anesthesia services provided on September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 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 the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment
at an acute care hospital (ACH) following several spinal surgeries. The enrollee was intubated/ventilated for
surgery and subsequently received a tracheotomy. The enrollee is currently described as being on minimal
ventilator support. It is unclear if there is an expectation of decannulation. As LTACHs and ACHs are licensed
to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee
can remain at the current ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral at the in-network rate for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The contract with the Plan clearly says that enrollees must pay 20% of the Medicare allowable amount for out-of-network services from a provider that accepts Medicare assignment.
You are not a network provider with the Plan. If the enrollee chooses to receive services with you, they will be asked to pay 20% of the Medicare allowable amount for these services. These services fall within the out-of-network services from a provider that accepts Medicare assignment benefit category. This means that the enrollee will be asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation that the enrollee agreed to pay when they enrolled in the Plan. The Plan has network providers from which the enrollee may receive services at the network level. Therefore, we decided that the Plan does not have to pre-approve a referral at the in-network rate for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (J2270, J2405, J2765, J1650, 93005, and
G0378) provided from August 23, 2019 to August 25, 2019.
You asked the Plan to pay for outpatient services. You say that these services were medically necessary. The
Plan denied your request. The Plan says these services were not authorized and could have been provided in network.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 outpatient services. Our reviewer says that
the services at issue were unauthorized post-stabilization services. Our physician reviewer found during the
emergency department stay under observation, the enrollee's condition was labeled as "fair" and the acute
exacerbation of gastroparesis had "improved." There was no mention or evidence of the enrollee being too
unstable for transfer to and in-network physician and location. Based on the provided documentation the
patient appeared to be stable for transfer on August 23, 2019.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of outpatient services have not been met. Therefore, we decided that the Plan does
not have to pay for outpatient services (J2270, J2405, J2765, J1650, 93005, and G0378) provided from August
23, 2019 to August 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs a total electric hospital bed for the height feature in order to safely transfer in and out of bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on April 29, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says there is no commensurate note in the medical record on or around that date as to why the brace was being ordered.
The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter includes information supporting that the beneficiary was evaluated or treated for a condition that supports the DME item ordered. We looked at the file and Medicare rules. There was no evidence in the documentation that the enrollee saw the doctor for a reason related to the prescribed orthosis. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on April 29, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for direct skilled nursing services (G0299) provided on September 1, 2019 through September 3, 2019.
You asked the Plan to pay for the skilled nursing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim form does not have the appropriate home health data to process and pay the claim.
The Plan must follow Medicare rules. Medicare rules say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. We find that CPT code G0299 is not supported in the record. Specifically, the claim does not have the appropriate Type of Bill 0329 and required Q code. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for direct skilled nursing services (G0299) provided on September 1, 2019 through September 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for alcohol detoxification services (H0010) provided from September 17, 2019 to September 23, 2019.
You asked the Plan to pay for alcohol detoxification services. You say that you expected to be reimbursed for these services. The Plan denied your request. The Plan says records have not been submitted to support these charges.
The Plan must follow Medicare rules. Medicare rules say that [or Medicare to consider coverage and payment for any item or service, the information submitted must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of alcohol detoxification services have not been met. Specifically, no medical records have been submitted to show that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for alcohol detoxification services (H0010) provided from September 17, 2019 to September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee by the provider on September 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 to the enrollee by the provider on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy (97110, 97167, 97542, G8978, G8979) provided on July 2, 2019 to July 17, 2019 by out of network provider.

You asked the Plan to pay for occupational therapy. You say that the applicable definition of medically necessary services to be, procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgement, would provide to a covered individual for preventing, evaluating, diagnosing, or treating an illness, injury or disease or its symptoms. The Plan denied your request. The Plan says The Hospital is a non-network provider that does not work with the Plan and a non-network provider referred and provided the services to the member. The member's primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.

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 occupational therapy (97110, 97167, 97542, G8978, G8979) provided on July 2, 2019 to July 17, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on September 6, 2019.You asked the Plan to payforthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 88184, 88185 and 88189 are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 88184 is flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker. The definition of code 88185 is flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker). The definition of code 88189 is flow cytometry, interpretation; 16 or more markers.We find that CPT codes 88184, 88185, and 88189 are not supported in the medical record. Specifically, there are no records for the date of service at issue to verify that the services were performed. 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 laboratory services rendered to the enrollee on September 6, 2019.