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

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on August 19, 2020.
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says this claim was billed with an incorrect place of service ode.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 99308 is not supported in the record. Specifically, this claim was billed with place of service code 31 which indicates the member is in a Part A covered SNF stay. The record does not show that the member is in a Part A covered stay, therefore this place of service code is incorrect. Based on this information, we decided that Medicare rules for coverage of the nursing facility care have not been met. Therefore, we decided that the Plan does not have to pay for the nursing facility care (99308) provided on August 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlaboratory services provided to the enrollee on March 18, 2020.You asked the Planto pay forthe services. You say that this was medically necessary.The Plandenied your request. The Plansaysthese services 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 had network providers available who could have provided 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 Plandoes not haveto pay forlaboratory services provided to the enrollee on March 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric hospital services.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can be treated in a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time. You do not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services.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 psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric hospital services.
Appeal type: Testing
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 September 18, 2020. 
 
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 had network providers 
available who could have provided 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 September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis rendered on March 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid proof of delivery.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis rendered on March 17, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided thatthe Plan does not have to pay forhearing aids (V5261) received on July 2, 2020.You asked the Plan to pay forhearing aids. You say that you were not given proper information by a representative of the Plan about your hearing aid coverage.The Plan denied your request. The Plan says rules for payment have not been met.The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services.Therefore, we decided that the Plan does not have to pay forhearing aids (V5261) received on July 2, 2020.Your complaint about receiving erroneous or ambiguous information about your benefits from the Planis not a valid appeal for medical coverage.This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe routine eyewear purchased on March 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the charges were applied correctly.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 for routine eyewear.We looked at the file and the Plan's rules. The file shows that you received routine eyewear on March 10, 2020 for a total of $290. The Plan covered $200 towards these services. The remaining $90 is your responsibility. The Plan applied a 20 percent discount off the remaining $90, leaving you with a total balance of $72. The remaining $72 is not covered by your supplemental benefit or your medical benefit. Therefore, we decided that the Plan does not have to pay forthe routine eyewear purchased on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe imaging services provided on August 21, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services are not payable.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The services in question were billed with POS 31. These services are not separately payable for POS 31. If the services were billed with the wrong POS code, then a new claim must be submitted. 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 forthe imaging services provided on August 21, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicare rules.The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was brought to the hospital for abnormal labs. The documentation shows that the enrollee is not safe to transition to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic cardiovascular risk assessment panel (81407, 81408 and 81439) provided on September 1, 2020.You asked the Plan to pay forthe genetic cardiovascular risk assessment panel. You say that you would like reconsideration because this testing was medically necessary.The Plan denied your request. The Plan says Medicare only covers the basic lipid panel.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pay for the genetic cardiovascular risk assessment panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found guidelines for medical therapy, coronary revascularization and other management of heart disease are available and do not recommend screening with a genetic risk panel.  Treatment based on the results of a genetic risk panel has not been shown to incrementally improve outcome compared to treatment based on standard clinical risk profiling and basic lipid results.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 genetic cardiovascular risk assessment panel have not been met.Therefore, we decided that the Plan does not have to pay forthe genetic cardiovascular risk assessment panel (81407, 81408 and 81439) provided on September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 23, 2020.
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 64722, 19340, 19371, and 24341 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 64722 is decompression; unspecified nerve(s) (specify).
The definition of code 19340 is immediate insertion of breast prosthesis following mastopexy, mastectomy or
in reconstruction. The definition of code 19371 is periprosthetic capsulectomy, breast. The definition of code
24341 is repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes
rotator cuff).
We find that CPT codes 64722, 19340, 19371, and 24341 are not supported in the medical record. Specifically,
the operative report does not include documentation of decompression of unspecified nerves to support code
64722. There is no documentation of repair of tendon or muscle to support code 24341. There is no
documentation of an immediate insertion of breast prosthesis to support code 19340. There is no
documentation of a periprosthetic capsulectomy of the breast to support code 19371.
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 surgical services rendered on July 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (88189, 88184, 88185) provided February 20, 2020.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were for screening purposes andwere not medically necessary.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 lab services at issue were requested solely for screening purposes. Insufficient records were provided to support that the labs were needed for reasons other than screening. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not have to pay forlab services (88189,88184, 88185) provided February 20, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reimbursethe cost share for several claims for services provided from January 2, 2019 to January 7, 2019.You asked the Plan to waive or reimbursefunds you believe were overpaid for services provided in 2019. You say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your request. The Plan says the claims in question were reviewed. The Plans portion of the services in question have been paidfor each service leaving your contractual copayment expectation of $25.00 and $50.00 for services rendered based on the service 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 in 2019 there was a maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in question. Both the records and the Explanation of Benefits (that you would also have a copy of ) for each service clearly show thebalance of the maximum out of pocket at the time of service. You have been asked to pay the correct amount for each service 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 or reimbursethe cost share for several claims for services provided from January 2, 2019 to January 7, 2019.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe removal of the lap band. We decided that the Plan does not have to pre-approvethe replacement with a gastric sleeve. You asked the Plan to pre-approvethe removal of the lap band and replacement with a gastric sleeve. You say that you would like reconsideration because the member is experiencing complications from their initial surgery.The Plan says that the symptoms listed are not technical failure of major complication of the initial procedure.We decided that the Planhas to pre-approvethe removal of the lap band. The Plan follows Medicare rules. Medicare rules say that 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 the removal of the lap band. Our reviewer says that lap band removal for complications of GERD is medically necessary and reasonable as there is no way to completely resolve any restriction without surgicalremoval of the foreign body. 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 removal of the lap band have been met.Therefore, we decided that the Plan has to pre-approvethe removal of the lap band. We also decided that the Plandoes not have to pre-approvethe replacement with a gastric sleeve.
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 replacement with a gastric sleeve. Our physician reviewer found the member has a BMI that is <35 kg/m2 at the current time and does not meet Medicare criteria forbariatric surgery.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 replacement with a gastric sleeve have not been met.Therefore, we decided that the Plan does not have to pre-approvethe replacement with a gastric sleeve.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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formyocardial perfusion imaging and does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 17, 2020.You asked the Plan to waive the copayment formyocardial perfusion imaging and to waive the coinsurance for a Medicare Part B drug injection. You say that you were not aware that you would owe such a high amount.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 $100 copayment for nuclear medicine. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.You received myocardial perfusion imaging on August 17, 2020. Therefore, you are responsible to pay the $100 copayment. You received a Medicare Part Bdrug injection on August 17, 2020. The allowed amount is $213.05 and 20% of that is $42.61. The total amount you owe is: $142.61. 
You have been asked to pay the total amount of $142.61 for myocardial perfusion imaging and a Medicare Part B drug injection. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic service and supplies benefit category. A Medicare Part B drug injection falls within theMedicare Part B prescription drugs benefit category. This means that youhave 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 formyocardial perfusion imaging and does not have to waive the coinsurance for a Medicare Part B drug injection provided on August 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing visits (CPT code(s): G0299, G0151, G0152 and G0156) to be provided by an out-of-network provider, for the enrollee.You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are available to be provided an in-network provider.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 services have not been met. This service is available by a provider in the enrollee's network. However, if the enrollee chooses to receive services from this out-of-network provider, the enrollee's cost for theircovered services may be higher.Therefore, we decided that the Plan does not have to pre-approveskilled nursing visits (CPT code(s): G0299, G0151, G0152 and G0156) to be provided by an out-of-network provider, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Vertiflex device for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of the health problem.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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer is experimental. More research isneeded to show safety and efficacy.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 pre-approvethe Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetumor treatment field therapy.You asked the Plan to pre-approvethe requested services. You say that the Optune is the best option for treating the enrollee's recurrent glioblastoma.The Plan denied your request. The Plan says coverage criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Tumor treatment field therapy is not reasonable and necessary for the treatment of recurrent GBMBased on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvetumor treatment field therapy.