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

We decided that the Plan has to pay for outpatient services (99213 and 99000) provided on January 18, 2018. You asked the Plan to pay for the outpatient services. You say that you would like reconsideration because the provider did not bill you until 2020. The Plan denied your request. The Plan says that you are responsible for any cost-shares related to the covered service.
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 does not say in clear and accurate terms how much your deductible amount is. We looked at your contract with the Plan. We did not see where the contract says how much enrollees can expect to pay before the Plan will pay their share. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Additionally, the Plan indicates that this service has been paid for, but there is no record of this payment in the file. The documentation submitted does not include and evidence of how this claim was processed. Therefore, we decided that the Plan has to pay for outpatient services (99213 and 99000) provided on January 18, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from October 18, 2019 to November 1, 2019. You asked the Plan to pay for the inpatient care. You say that the plan did not authorize this admission or start the transfer within two hours. Once two hours passed, the enrollee was admitted and did not need to be sent to any other facility. The Plan denied your request. The Plan says it was decided on peer to peer that the enrollee would be transferred to a network facility which the out of network facility then cancelled when they admitted the stable enrollee without authorization. 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 the inpatient care. Our reviewer says that the enrollee was stable for transfer at the time of admission and authorization for inpatient care was not provided. Our physician reviewer found the enrollee presented to an out of network ED on 10/18/2019 with increased agitation and mental status changes. The review has determined that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for admission after the emergency room evaluation on 10/18/19. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. The review has determined that the inpatient status and subsequent care provided from 10/18 to 11/1/2019 was not medically necessary or reasonable to be provided by the out of network facility. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from October 18, 2019 to November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup services.
You asked the Plan to pre-approve core buildup services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core buildup services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Keytruda and Alimta.
You asked the Plan to pre-approve Keytruda and Alimta. You say that this is a continuation request. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because this regimen is not in accordance with NCCN recommendations.
The Plan follows Medicare rules. Medicare rules say that chemotherapy drugs may be covered if they are medically necessary, FDA approved, and used according to NCCN recommendations. 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 Keytruda and Alimta. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Keytruda and Alimta. Our physician reviewer found this combination of drugs is not Food and Drug Administration (FDA) approved. The combination is not supported in any of the Medicare-approved compendia to treat an enrollee who has had progression of cancer on Keytruda and who has been treated second line with Alimta and Keytruda followed by Alimta, Keytruda, and Carboplatin. Therefore, the request does not meet Medicare coverage criteria and is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda and Alimta have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Keytruda and Alimta.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on September 23, 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 code G0483 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug
classes.
We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation
of testing of 22 or more drug classes. 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 definitive
drug testing rendered on September 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 3, 2019 to
November 4, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan
denied your request. The Plan says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the services were medically necessary. Our physician reviewer found the enrollee presented to the
emergency department (ED) on November 2, 2019 with epigastric pain for three days. The pain was described
as 10 out of 10 severity and was unrelieved by Pepcid, Zantac, and omeprazole. She was admitted and
evaluated by gastroenterology. She underwent an upper endoscopy on November 4, 2019 which demonstrated
a submucosal gastic lesion without bleeding that was biopsied. The records show that, at the time of the
inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care
(including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided November 3, 2019 to November 4, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 additional home health visits for a total of 12.
You asked the Plan to pre-approve additional home health visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional home health visits. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has a medical history of hypertension, chronic back pain, benign prostatic enlargement and lower extremity venous insufficiency. The enrollee has been receiving home health nursing services related to lower extremity venous stasis wounds and catheter care. The documentation do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration for the six additional home health nursing visits requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 additional home health visits for a total of 12.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (15734-GC, 15734-76-GC) provided on November 25, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk". 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 codes 15734-GC and 15734-76-GC is not supported by the records provided. Our physician reviewer found that the medical records provided do not include documentation of a "Muscle, myocutaneous, or fasciocutaneous flap; trunk" being performed on November 25, 2019, therefore these service cannot be verified. 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 (15734-GC, 15734-76-GC) provided on November 25, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to waive the charges for the chemotherapy services provided from May 2, 2019 to May 23, 2019.
You asked the Plan to waive the charges for the chemotherapy services. You say that you are being billed for $858.61 from this provider but you had already paid more than $4900 for 2019. The Plan denied your request. The Plan says that all claims were processed correctly and you met the maximum amount when the claim was reprocessed.
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. There is no way to determine from the information in the case file whether the claim for these services was processed correctly. The documentation shows that the Plan paid $225 toward this claim, assigning you a balance of $858.61. It is unclear how this charge was calculated. The Plan indicates that the maximum out of pocket was not met until the claim reprocessed; however, there is not  any evidence to support this. Regardless of whether the maximum out of pocket was met, the Plan has not provided sufficient information to support that the claim for these services was processed correctly or that you were asked to pay the correct amount based on your contract. Therefore, we decided that the Plan has to waive the charges for the chemotherapy services provided from May 2, 2019 to May 23, 2019.
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 you were independent prior to this admission and the intensity of an IRF is needed to help you return to your prior level of function in the safest and quickest way. You say that you need close medical supervision from a physical medicine and rehabilitation physician. The Plan denied your request. The Plan says the records do not indicate that the criteria for coverage of IRF care have been met. The Plan says that the enrollee can receive the services needed in another setting. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital care provided from
January 3, 2020, to January 8, 2020.
You asked the Plan to waive the copay for the inpatient care. You say that you were told your hospital stay
would be $250. The Plan denied your request. The Plan says the copay was applied correctly based on your
plan 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). Your contract with the Plan clearly says that you must pay a $250
copay per day for days 1-6 for inpatient hospital care.
You have been asked to pay a $1250 copay for the inpatient care. The services fall 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 copay for the inpatient hospital care provided
from January 3, 2020, to January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical fusion surgery.
You asked the Plan to pre-approve cervical fusion surgery. The Plan denied your request. The Plan says this 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 cervical fusion surgery. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no clearly documented neurologic deficit. The enrollee's last exam was normal. There is no correlation between exam and imaging matching nerve root compression. There is no instability. Criteria for the requested surgery are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical fusion surgery.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on March 15, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. 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 $120 copayment for Medicare-covered emergency room visits. You have been asked to pay a $120 copayment for the emergency room visit. The 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 the emergency room visit provided on March 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $50 to $20 for each hyperbaric oxygen therapy treatment (G0277) provided from September 30, 2019 to December 16, 2019. You asked the Plan to adjust the copayment for each hyperbaric oxygen therapy treatment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the services provided. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment per visit for outpatient hospital services. You have been asked to pay a $50 copayment per visit for the hyperbaric oxygen therapy treatment provided. 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 adjust the copayment from $50 to $20 for each hyperbaric oxygen therapy treatment (G0277) provided from September 30, 2019 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 9, 2020. You asked the Plan to waive the copayment for the office visit. You say that you paid your copayment. You say that this is bad billing. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was provided by a specialist. 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 office visit provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 22, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 services at issue in this appeal. The Plan did not pre-approve the services 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 the medical services provided to the enrollee by an out-of-network provider on November 22, 2019.