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

We decided that the Plan does not have to pay forthe preventive comprehensivepreventive reevaluation provided on September 9, 2019 by the out of network provider.You asked the Plan to pay forthe physician services. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan also says the services could have been provided in 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 provider in this case is not a network provider with the Plan. The Plan has confirmed there are network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe preventive comprehensive preventive reevaluation provided on September 9, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided to the enrollee on July 5, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. An appeal was submitted by the provider with no new medical records. Documentation submitted on appeal consists of an Appeal Letter and duplicates of records previously reviewed. Healthcare Common Procedure Coding System (HCPCS) code E0466 RR remains not supported. The medical records submitted do not include a signed delivery sheet or proof of delivery of when the patient received the supply billed. Therefore, the billed supply code cannot be verified. Of note, the Rental Agreement does not contain a statement verifying delivery to the patient and precedes the order date. It is noted that multiple attempts were made to contact the provider for additional information. Therefore, we decided that the Plan does not have to pay for home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (CPT Code E0466) provided to the enrollee on July 5, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on July 17, 2019.
You asked the Plan to pay for the acute inpatient hospital care provided on July 17, 2019. You say that the acute inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital care provided was not medically necessary and could have been provided at a lower 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 the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department on July 13, 2019 with increased shortness of breath and right groin pain. The evaluation revealed increased Congestive heart failure. She was admitted for IV diuresis. She was evaluated by Orthopedics and underwent imaging services which demonstrated no fracture. She was treated with IV Morphine and oral Oxycodone for pain control. Her Chronic obstructive pulmonary disease (COPD) was managed with inhaler therapy. Her condition stabilized and improved and she was discharged home on July 18, 2019 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission, the admitting physician reasonably expected that the patient'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 on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis provided by "the provider" on July 10, 2019.You asked the Plan to payforthe knee orthosis (L1851). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says there are no records supporting medical necessity.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. There is no clinical documentationofan exam showing knee instability.Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1851) have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis provided by "the provider" on July 10, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not have to pay forinpatient neuromuscular procedures coded as 95938, 95937, 95870 provided September 4, 2019.You asked the Plan to pay forinpatient neuromuscular procedures. You say that the facility does not provide their own technicians nor do they own any equipment used for the nerve monitoring process. You own all of your durable equipment and provide the disposable supplies used.The Plan denied your request. The Plan says Medicare procedures requires modifier 26 per Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services at issue (95938-TC, 95870-TC, 95937-TC) have not been met. Specifically, technical component procedures are institutional and cannot be billed separately by the physician when the patient is inpatient. The claim was billed with Place of Service 21, indicating the patient was inpatient. In addition, 95937 is not supported by the medical record. It appears that this code was reported for train of four testing.  Train of four is included in other neuromonitoring services and is not separately reportable. Based on this information, we decided that Medicare rules for coverage of inpatient neuromuscular procedures have not been met.Therefore, we decided that the Plan does not have to pay forinpatient neuromuscular procedures coded as 95938, 95937, 95870 provided by September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe lab services provided on June 19, 2019.You asked the Planto pay forthe OON lab services. You say that this should be paid on the basis of medical necessity.The Plandenied your request. The Plansaysthis non-emergency lab testing was performed without obtaining authorization from the Plan. This is not covered in this situation.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 issuein 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 Plandoes not haveto pay forthe lab services provided on June 19, 2019 by the out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa injections.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have right knee osteoarthritis confirmed by x-rays. You have failed conservative treatments. The records show that you have not tried and failed the plan's required drugs of orthovisc and monovisc. The records do not show that the required drugs would be less effective or contraindicated; therefore, Euflexxa is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. 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 pre-approveEuflexxa injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on September 6, 2019.You asked the Plan to waive the copayment foran X-ray. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each basic imaging service. You have been asked to pay a $40 copayment for an X-ray. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies 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 foran X-ray providedr on September 6, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe "cancer gene sequencing panel" provided to the enrollee on March 9, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is no history of kidney disease.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 pay for the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found no provider records have been submitted for review. The lab paperwork indicates that the enrollee does not have a personal history of cancer. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).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 Plandoes not haveto pay forthe "cancer gene sequencing panel" provided to the enrollee on March 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fornon-emergent ambulance services provided to the enrollee on October 7, 2018.You asked the Plan to pay fornon-emergent ambulance services. You say that the service is medically necessary.The Plan denied your request. The Plan says the service is not medically necessary.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. There is no evidence in the available medical information of medically necessary transfer to higher level of care facility. Per Medicare rules and SCAN Evidence of Coverage, this was non-emergent Advanced Life Support transportation and does not qualify for Emergency coverage. Furthermore, there was no prior authorization. Prior authorization rules apply for non-emergency ambulance services. The destination was not the closest facility that could provide for the patient's needs. The transportation and transfer appear to be member/family desire and as such they are responsible.Therefore, we decided that the Plan does not have to pay fornon-emergent ambulance services provided to the enrollee on October 7, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography angiography (CTA).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CTA of the heart is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has known coronary disease but no symptoms or documented objective findings of coronary ischemia. There is no documented covered indication for this procedure. Specifically, there is no documented chest pain syndrome, no documentation congenital coronary anomaly, no documented equivocal stress test result and no other documented need to assess coronary anatomy without invasive coronary angiography.We looked at this physician's review, the file, and Medicare rules. 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 pre-approvecomputed tomography angiography (CTA) of heart
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus immunization and related administration (90714 and 90471) provided on August 28, 2019.
You asked the Plan to pay for the tetanus immunization and related administration. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus immunization and related administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the tetanus immunization and related administration. Therefore, we decided that the Plan does not have to pay for the tetanus immunization and related administration (90714 and 90471) provided on August 28, 2019.
Benefits for the tetanus immunization and related administration 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 pay forinpatient hospital care provided to the enrollee from January 18, 2019 through January 20, 2019.You asked the Plan to pay forinpatient hospital care. You say that the claim should be paid.The Plan denied your request. The Plan says the stay is not medically necessary.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 inpatient hospital care. Our physician reviewer found the review has determined that after 3:36 p.m. on January 18, 2019, the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for continued inpatient/observation level of care services. Post-stabilization care services at the non-participating Plan facility after 3:36 p.m. on January 18, 2019 were not medically necessary and reasonable. 
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.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not beenmet.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided to the enrollee from January 18, 2019 through January 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on September 16, 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 show that you received inpatient hospital care on September 16, 2019. You are asked to pay a $350 copayment for the inpatient hospital care. 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 on September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance imaging, any lower extremity, provided on February 15, 2019 bytheout of network provider.You asked the Plan to pay forthe radiology service. You say that the provider advised that they had gotten approval from the insurance company before the test was done.The Plan denied your request. The Plan says authorization was not obtained before you received the service.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 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 payfor these items/services.Therefore, we decided that the Plan does not have to pay forthe magnetic resonance imaging, any lower extremity, provided on February 15, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided on August 7, 2019.
You asked the Plan to pay for the assistant services. The Plan denied your request. The Plan says the procedure codes do not allow an assistant surgeon payment.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT codes 24105 and 24147. The Medicare Fee Schedule Database contains a surgical indicator of 1 for these procedures. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided on August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided at "the provider" from May 30, 2019 toJune 4, 2019.You asked the Plan to waive the copayment foran inpatient hospital stay. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from May 30, 2019 to June 4, 2019. Therefore, you are responsible to pay a $325 copayment per day for days 1-4 (May 30, 2019 to June 3, 2019). $325 (copayment) x 4 (inpatient days) = $1,300.00.You have been asked to pay the total copayment amount of $1,300.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided at "the provider" from May 30, 2019 to June 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Open Magnetic Resonance Imaging (MRI) (72148) to be provided by out of network provide.You asked the Plan to pre-approve the open MRI. You say that the enrollee needs the MRI because an open MRI is required due to patient's size.The Plan denied your request. The Plan says the provider can provide the services at issue and is in-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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the Open Magnetic Resonance Imaging (MRI) (72148) to be provided by out of network provider.