Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 12032) provided on August 13, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.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 12032 is Documentation submitted was reviewed. Emergency Room visit does not clarify would size, and treatment received to support code 12032.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 services. Our reviewer says that the use of CPT code 12032 is not supported by the records provided. Our physician reviewer found that the emergency room visit does not clarify wound size, and treatment received to support code 12032.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 services have not been met.Therefore, we decided that the Plan does not have to pay for the services (CPT 12032) provided on August 13, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit on January 13, 2020.
You asked the Plan to waive the copayment for the Emergency Room Visit. 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 $120 copayment for Emergency Care. You have been asked to pay a $75.11 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care benefit category. The allowable amount is less than the $120 stipulated in the plan contract. 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 on January 13, 2020.We decided that the Plan does not have to waive the copayment for an Emergency Room Visit on January 13, 2020.
You asked the Plan to waive the copayment for the Emergency Room Visit. 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 $120 copayment for Emergency Care. You have been asked to pay a $75.11 copayment for the Emergency Room Visit. The Emergency Room Visit falls within the Emergency Care benefit category. The allowable amount is less than the $120 stipulated in the plan contract. 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 on January 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for and pay for an emergency room visit and self-administered drugs provided on December 4, 2019.You asked the Plan to waive the copayment for and pay for emergency room visit and self-administered drugs. You say that the provider said there was nothing he could do and did not help with the enrollee's problem.The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct. The Plan also says that the denial of payment for self-administered drugs 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). The rules say that Medicare Part B generally does not pay for self-administered drugs. The enrollee's contract with the Plan clearly says that enrollees must pay $90 copayment for emergency room visit. The enrollee has been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.The self-administered drugs provided are not covered by Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment for and pay for an emergency room visit and self-administered drugs provided on December 4, 2019.Benefits for self-administered drugs 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 an IRF admission and services.You asked the Plan to pre-approve IRF care. You say that further delay in care would have a detrimental effect in the safety and ability to recover to the fullest extent possible. The Plan denied your request. The Plan says you do not meet criteria for an IRF.The Plan mustfollow 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 determineif the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer foundthat the medicalrecords do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF)level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF.You are mostly MAX assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy may be more appropriate. 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 an IRFadmission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a gastric bypass procedure.
You asked the Plan to pay for the procedure. The Plan denied your request. The Plan says this procedure was
not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees
who have:
(1) a body mass index (BMI) of greater than or equal to 35;
(2) at least one co-morbidity related to obesity; and
(3) been unsuccessful with medical treatment for obesity.
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 procedure. Our reviewer says that the
requested surgery is not medically reasonable and necessary. Our physician reviewer found that height and
weight are not provided for the enrollee to determine BMI. There is no documentation of failed dietary efforts.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pay for a gastric bypass procedure.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on September 18, 2019.
You asked the Plan to pay for lab tests. You say that you are appealing with attached records. The Plan denied
your request. The Plan says that the denial of payment for these services is correct, because progress notes from
the ordering provider were not submitted to show the clinical utility of the testing.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering provider was in-network or outof-
network with the Plan. The documentation submitted does not include prior notice from the Plan that these
tests would not be covered. Without this information, we cannot determine whether the lab order made
constitutes plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these
services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory
testing provided on September 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Arikayce for the enrollee.
You asked the Plan to pre-approve Arikayce. You say that Arikayce is medically necessary. The Plan denied
your request. The Plan says Arikayce is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Arikayce for the enrollee.
Benefits for Arikayce 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered from June 20, 2019 to June 21, 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 procedure codes 99152 and 99153 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 is moderate sedation services by physician also performing a procedure, patient 5 years of age or older, first 15 minutes. The definition of code 99153 is moderate sedation services by physician also performing a procedure, additional 15 minutes. We find that CPT codes 99152 and 99153 not supported in the medical record. Specifically, there is no documentation of an independently trained observer to assist in monitoring the patient's level of consciousness and physiological status for the first 15 minutes and beyond the initial 15 minutes. 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 moderate sedation services rendered from June 20, 2019 to June 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on June 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment, The Plan denied your request. The Plan says the enrollee was not covered under the inpatient skilled nursing facility benefit at the time of the services being rendered.
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 skilled nursing services provided on June 19, 2019 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that this was an extension of an office visit. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer these services. The Plan says that no prior authorization was obtained.
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 lab work provided on December 19, 2019 by an out of network (OON) 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 for the enrollee.You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for IRF care are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on review of the available medical records, the enrollee is medically stable with no evidence of need for supervision by PMR Physicians or a need for acute rehab nursing care. Functionally has dementia and does not require an intensive therapy program. It is not clear he can participate in the intensity of an IRF program. IRF admission criteria are not met based on the enrollee's medical stability.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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an OB/GYN office visit provided on February 13, 2020 by an out of network (OON) provider.You asked the Plan to pay for an OB/GYN office visit. You say that you have used this provider for the last 35 years. You say that you picked this plan because your provider was in-network.The Plan denied your request. The Plan says there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 OB/GYN office visit provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve obinutuzumab.You asked the Plan to pre-approve obinutuzumab. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 obinutuzumab. Our reviewer says that obinutuzumab is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that single agent obinutuzumab plus dexamethasone is not a standard treatment for follicular lymphoma. It is generally used with a backbone chemotherapy agent such as bendamustine.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of obinutuzumab have not been met.Therefore, we decided that the Plan does not have to pre-approve obinutuzumab.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 16, 2020 by a non-network provider.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 services were rendered by a non-network provider without prior authorization.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 January 16, 2020 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 19, 2019.You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records to support the lab billed.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on March 12, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services that you provided on March 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 21, 2020.
You asked the Plan to pay for the physician's services. -The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on January 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injections provided on February 13, 2019.
You asked the Plan to waive the coinsurance for the injections. You submitted your bill for review. You say that the bill was sent almost a year later. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% of the Medicare-allowed amount for in-network Medicare Part B-covered drugs and Medicare Part B-covered chemotherapy drugs. You have been asked to pay $1,025.16, which is less than the standard 20% coinsurance for the injections. The injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the injections provided on February 13, 2019.