Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forphysical therapy services (97110 and 97530) provided to you by an out-of-network provider, from  April 1, 2019 to May 29, 2019.You asked the Plan to waive the deductible forout-of-network physical therapy services. You say that you should only be charged a coinsurance for these services.The Plan denied your request. The Plan says these services processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for out-of-network services. The item or service youasked the Plan to waive the deductible for falls within the benefit category out-of-network services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network services. This cost sharingis a contractual obligation that had not been met at the time out-of-network physical therapy services were received on April 1, 2019 to May 29, 2019.Therefore, we decided that the Plan does not have to waive the deductible forphysical therapy services (97110 and 97530) provided to you byan out-of-network provider, from  April 1, 2019 to May 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on July 30, 2019.
You asked the Plan to pay for the lab services. You say that the testing is medically necessary. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the lab services ordered following the non-covered visit are likewise
non-covered. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services provided on September 16, 2019 and the office visit provided on September 18, 2019.
You asked the Plan to waive the copayments for the laboratory services and office visit. You say that you were informed there would be no charge for a follow up to surgery. 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 $10 copayment for each Medicare covered laboratory test and a $40 copayment for a Medicare covered specialist visit. You have been asked to pay a $10 copayment for the laboratory services and a $40 copayment for the office visit. The total amount you owe is $50 ($10 + $40 = $50). The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was not within the 90-day follow up period.
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 copayments for the laboratory services provided on September 16, 2019 and the office visit provided on September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 10, 2019 to September 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated at an observation level of care.
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 enrollee presented to the emergency department on September 10, 2019 with cough and weakness. Her physical exam was essentially unremarkable and labs revealed a normal troponin and an elevated Pro-B-type natriuretic peptide. The electrocardiogram was without acute ischemic changes and the chest x-ray revealed mild congestive heart failure. She was treated with Lasix and Nifedipine. Her condition stabilized and improved and she was discharged home on September 11, 2019 with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital 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 for the acute inpatient hospital care provided from September 10, 2019 to September 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit for the evaluation and management of an
established patient (99349) provided on July 19, 2019 by the out of network provider.
You asked the Plan to pay for a home visit for the evaluation and management of an established patient. You
say that you are asking for a reconsideration based on the lack of options and rejections from the other house
call providers in the area and the patient's limited mobility. You say you are still trying to become in-network. You also say that a loss of all these prior dates of service will cause an immediate shut down of your practice and these patients will be forced to rely on ambulance trips to the emergency room for even the most routine of care. The Plan denied
your request. The Plan says the provider is a non-network provider who does not work
with the member's health plan, and the member was referred, who also does not work
with the member's plan. The member's primary care physician 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 a home visit for the evaluation and management of an established patient
(99349) provided on July 19, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy (0275T).
You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy. You say that this is medically
necessary. The Plan denied your request. The Plan says that surgical treatment of your condition is not
medically necessary.
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 a percutaneous
laminotomy/laminectomy. Our reviewer says that the requested services are not considered medically
reasonable and necessary in this case. Our physician reviewer found percutaneous laminotomy/laminectomy is
experimental. More research is needed to show safety and efficacy. It is not within the care standard.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a percutaneous laminotomy/laminectomy have not been met. Therefore, we
decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay an additional reimbursement amount for an office visit with a specialist (99215) provided on July 15, 2019.
You asked the Plan to pay an additional reimbursement amount for an office visit with a specialist. You say that the reimbursement was paid incorrectly and that you are owed an additional $439.63. You say that there were six other procedures done during the visit in question and you are asking the health plan for additional reimbursement of those out of pocket expenses. The Plan denied your request. The Plan says the enrollee's claims did not deny and they were processed correctly according to the 2019 benefit plan design. The Plan says that the enrollee is responsible for the cost share that applied. The Plan further says that the enrollee submitted a paid receipt for services in amount of $263.33. The claim processed correctly by applying the member's $25.00 copayment for a specialist's office visit and reimbursing the member $131.39.
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 $25 copayment for physician services. You have been asked to pay a $25 copayment for an office visit with a specialist. This service falls within the physician services with a specialist benefit category. The records shows $263.33 is the amount billed for the service. However, the amount allowed minus what the Plan paid is your cost share responsibility ($156.39 - $131.39 = $25.00). This is why you were reimbursed the correct amount. 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 pay an additional reimbursement amount for an office visit with a specialist (99215) provided on July 15, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on
November 16, 2018.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that the provider would
not change the coding for the procedure. You say that you shouldn't be responsible for clerical errors. 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 $275
copayment for Medicare-covered surgery from an in-network provider.
You have been asked to pay a $275 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy
falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers" benefit category. The records show that the colonoscopy was ordered for
diagnostic purposes. 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 diagnostic colonoscopy
provided on November 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetherapeutic apheresis for the enrollee.You asked the Plan to pre-approvetherapeutic apheresis. The Plan denied your request. The Plan says that high cholesterol is not a covered indication.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 therapeutic apheresis. Our reviewer says that therapeutic apheresis is not medically reasonable and necessary for the enrollee. The enrollee has a past medical history of homozygous familial hyperlipidemia, coronary artery disease and coronary artery bypass graft at age 29. The enrollee's LDL on Repatha is 436. The request for apheresis is for hyperlipidemia. This is not a covered indication. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for therapeutic apheresis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapeutic apheresis have not been met.Therefore, we decided that the Plan does not have to pre-approvetherapeutic apheresis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on September 10, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service September 10, 2019. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 an office visit (99213) provided on September 10, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 19, 2019 through November 7, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says there is no valid proof of deliver.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 19, 2019 through November 7, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve F2 gene analysis and F5 genetic analysis.
You asked the Plan to pre-approve the F2 gene analysis and F5 genetic analysis. You say that the records provided support the need for the requested genetic testing. The Plan denied your request. The Plan says that the enrollee does not have a covered indication for the requested genetic testing. The Plan says that a first clot at age 74 would strongly suggest no genetic cause for hypercoagulability.
The Plan must follow Medicare rules. Medicare rules say that Medicare may consider coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will change clinical management of the patient. 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 F2 gene analysis and F5 genetic analysis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 74-year-old woman with recent unprovoked deep vein thrombosis and pulmonary embolus. There is a family history of thrombosis in father and two sisters. She is currently treated with Eliquis. There is no history of bleeding complications. There is no documentation of a high risk for bleeding complications. The treating provider is a hematology/oncology specialist who states that, given the unprovoked nature of the thrombosis and strong family history of thrombosis, results of testing would affect management, informing a decision regarding length of treatment. 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 F2 gene analysis and F5 genetic analysis have been met. Therefore, we decided that the Plan has to pre-approve F2 gene analysis and F5 genetic analysis.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on August 5, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on August 5, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on July 22, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for this copayment. You say the doctor did not examine you or take your blood pressure. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency Care" benefit category. The record shows you went back to an exam room and had a IV started. Therefore, you received services during your emergency room visit.
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 emergency room visit provided on July 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCT scan of the chest.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthisis not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the accepted guidelines for the follow-upof incidental pulmonary nodules of less than 6 mm in diameter are specific for a one year follow-up, not 6 months as ordered by the referring clinician. Furthermore, the recommendation included by the interpreting radiologist on the CT of the abdomen and pelvis on 4/13/19 specified the recommendations advocated by the guidelines as a one year follow-up. Hence, the CT of the chest of 10/21/19 did not comply with accepted guidelines and should not be reimbursed.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCT scan of the chest.