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

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on
October 10, 2019, October 14, 2019 and October 18, 2019.
You asked the Plan to waive the copayment for the ambulance transports. You say that The Plan denied your
request. The Plan says that copayments are a member's contractual obligation.
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 $200
copayment for per one-way ambulance trip.
You have been asked to pay a $200 copayment for each of the ambulance transports. The ambulance transports
fall within the one-way ambulance trip 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 ambulance transports provided on October 10, 2019, October 14, 2019 and October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy provided from November 22, 2019 to November 26, 2019. You asked the Plan to waive the copayments for radiation therapy. You say that you disagree with the charges and feel that they are too high. 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 $60 copayment for radiation therapy. You received radiation therapy from November 22, 2019 to November 26, 2019 for a total of 3 services. Therefore, you are responsible to pay a $60 copayment per each service. The total amount you owe is: $180. You have been asked to pay the total copayment amount of $180 for radiation therapy. Radiation therapy 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 copayments for radiation therapy provided from November 22, 2019. to November 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve the additional PT visits. You say that you have not been given any range of motion therapy in which you have been observed by your therapist, and all of your treatment sessions have been massage therapy based, with suggestion to work on range of motion exercises at home. The Plan denied your request. The Plan says 8 additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found based on the medical records provided, the documentation does not support the medical necessity of 8 additional PT visits. The therapy would not be generally accepted as specific and effective therapy for your condition as you have had extensive therapy for this condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You should be able to transition to an independent home exercise program at this point for range of motion, strengthening and pain management. 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 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services provided on September 19, 2019 by an
out-of-network provider.
You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your
request. The Plan says they did not authorize any services for the provider who is a non-participating provider.
The Plan states the services are not considered urgent/emergent in nature. The Plan states there are multiple innetwork
providers within 30 miles of the members residence that could have rendered the 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 the office services provided on September 19,
2019 by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forgenetic test. You say that Medicare covers this test and you are the only provider capable of performing this testing.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this testing is not covered by Medicare, this provider is out-of-network with the Plan, and prior authorization was not 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 Plan contract also says that prior authorization must be obtained for all genetic testing, whether that testing is to be provided by an in-network or out-of-network provider. The requested provider in this case is not a network provider with the Plan. Prior authorization for this testing was not obtained according to the Plan's clearly stated requirements. 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 medical services provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided to the enrollee on
July 19, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this was denied as a duplicate claim line, because it had been previously processed.
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 99309 is "Subsequent nursing facility care, per day, for
the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed
interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or
coordination of care with other physicians, other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient has
developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the
bedside and on the patient's facility floor or unit."
We find that CPT code 99309 is not supported in the medical record. Specifically, the file shows that this code
was previously paid for. The code is a duplicate charge. 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 subsequent nursing facility care provided to the enrollee on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on August 24, 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 01992 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 01992 is anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position. We find that CPT code 01992 is not supported in the medical record. Specifically, the records do not support the use of anesthesia without the billing of the G9 modifier. 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 anesthesia services rendered on August 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 1, 2019 to October 23, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan. The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 21, 2019 to September 24, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 1, 2019 to October 23, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to care for herself if discharged home. The Plan denied your request. The Plan says the enrollee has no skilled therapy or nursing needs.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee is at a contact guard assist level with functional mobility. She requires varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 3, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you should not be charged this amount because you had no other way of getting to the rehab center.The Plan denied your request. The Plan says that the claim processed 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 $300 copayment for per ambulance transport. You have been asked to pay less than a $300 copayment for the ambulance transport. The ambulance transport falls within the ambulance transport benefit category. This means that you have been asked to pay less than the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed topay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 3, 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 the enrollee's medical complexity and functional decline have continued during the enrollee's hospitalization. Receiving 3 hours of therapy per day for at least 5 days per week would be beneficial to the enrollee. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional therapies of physical therapy and occupational therapy, but the enrollee does not require this on an intensive rehabilitation program level in an IRF.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the heart image PET, an imaging supply, and the Part B drug provided on March 25, 2019.
You asked the Plan to waive the cost sharing for the heart image (PET), the imaging supply, and the Part B drug. You say that the billing is incorrect and you say you were never told there would be any charges. 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 $200 copayment for PET scan/nuclear imaging service, 20% coinsurance for Medicare-covered therapeutic radiological services, including technician materials and supplies, and 20% coinsurance for Medicare-covered Part B drugs. You have been asked to pay a total of $433.64 for the heart image (PET), the imaging supply, and the Part B drug. The heart image (PET) and the imaging supply falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B drug falls within the "Medicare Part B preDate of Service
Service
Allowed Amount
Copayment/Coinsurance
Member Liability
March 25, 2019
Heart image (PET)
$1,533.56
$200.00
$200.00
March 25, 2019
Imaging supply
$937.35
20%
$187.47
March 25, 2019
Part B drug
$230.84
20%
$46.17
Total
$433.64
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 cost sharing for the heart image PET, the imaging supply, and the Part B drug provided on March 25, 2019.scription drugs" benefit category. See chart below.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a needle electromyography provided on April 16, 2019.You asked the Plan to waive the copayment for a needle electromyography. You say that you disagree with the additional $150 charge.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 $0 copayment for EKG and diagnostic colorectal screenings and a $150 copayment for all other diagnostic procedures and tests. You have been asked to pay a $150 copayment for a needle electromyography. A needle electromyography 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 fora needle electromyography provided on April 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate cancer screening; prostate specific antigen test
(PSA) (CPT Code G0103) provided on November 13, 2019.
You asked the Plan to pay for the services. You say that the services should be covered because the doctor
recommended it. The Plan denied your request. The Plan says you exhausted your benefit.
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. You exhausted your benefit
because you had this service performed on May 11, 2019. Your EOC clearly states, for men age 50 and older,
covered services include the following - once every 12 months: Digital rectal exam or a Prostate Specific
Antigen (PSA) test. Therefore, we decided that the Plan does not have to pay for prostate cancer screening;
prostate specific antigen test (PSA) (CPT Code G0103) provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe compression system application provided from August 13, 2019 through September 18, 2019.You asked the Plan to waive the copayment forthe compression system application. You say that these appointments were for wound care. You say that the Plan should have paid on the charges.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital.You have been asked to pay a total of $744.84 for the compression system application. Date of ServiceAllowed AmountStandard CopaymentMember LiabilityAugust 13, 2019$124.14$325$124.14August 20, 2019$124.14$325$124.14August 27, 2019$124.14$325$124.14September 4, 2019$124.14$325$124.14September 11, 2019$124.14$325$124.14September 18, 2019$124.14$325$124.14TOTAL:$744.84 The compression system application falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 forthe compression system application provided from August 13, 2019 through September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on May 14, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on May 14, 2019.