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

We decided that the Plan does not have to pay for an office visit provided on July 22, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that requesting payment for services that have been provided.The Plan denied your request. The Plan says no prior authorization was obtained for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for an office visit provided on July 22, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Radiology services (71045, 74177, 74018, 71260) provided August 11, 2019 to August 12, 2019 by Radiology Physician Solutions.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is a duplicate.
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 find that CPT codes 71045, 74177, 74018, and 71260 are not supported in the medical record. Specifically, the record shows the claim is a duplicate of another claim, which was processed and paid on October 9, 2019. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for Radiology services (71045, 74177, 74018, 71260) provided August 11, 2019 to August 12, 2019 by Radiology Physician Solutions.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 11, 2019 and billed under code 99212-25.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the CMS Correct Coding Initiative (CCI) has identified column I procedure codes and their associated column II procedure codes based on the principles of correct coding. Services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code. Procedure code 99212-25 was denied as the column II code to the column I code 01480 based on the CCI policy 'HCPCS/CPT Procedure Code Definition'. The Column I code was paid therefore the Column II code on claim is not payable.
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, code 99212-25 cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on July 11, 2019 and billed under code 99212-25.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 for the drug testing rendered on April 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from February 9, 2020 through February 19, 2020, for the enrollee.You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 mental health care. Our physician reviewer found based upon review the records provided for the admission of this patient does not meet criteria for acute inpatient mental health treatment as she was not shown to be a danger to herself or others, no auditory or visual hallucinations. She is noted to be cooperative and compliant with treatment while not showing any aggressive behaviors.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 mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from February 9, 2020 through February 19, 2020, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the charges for the lab testing provided on October 1, 2019 and October 18, 2019.
You asked the Plan to waive the charges for the lab testing provided by a hospital. You say that you feel that this charge is incorrect because you do not have copayments for labs on your plan. The Plan denied your request. The Plan says you were correctly charged the $35 copayment for lab testing provided by the hospital.
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 $35 copayment for lab services provided by an outpatient hospital. You have been asked to pay a $35 copayment for the lab testing provided by a hospital for each date. The lab testing within the lab services provided by an outpatient hospital 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 charges for the lab testing provided on October 1, 2019 and October 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intraoperative neurophysiology monitoring (G0453) provided on May 29, 2019.You asked the Plan to pre-approve the intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is experimental or investigational.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 intraoperative neurophysiology monitoring. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found surgery was done below the level at which the spinal cord terminates, and none of the Medicare indications for coverage were 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 the intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pre-approve intraoperative neurophysiology monitoring (G0453) provided on May 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospitalization for airway sizing and insertion of bronchial valve.
You asked the Plan to pre-approve inpatient hospitalization for airway sizing and insertion of bronchial valve. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 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 hospitalization for airway sizing and insertion of bronchial valve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is usually an outpatient procedure and is being attempted electively. The member can be observed and monitored in the hospital overnight after the procedure. However, in the absence of unexpected complications or other medical instabilities, monitoring after the procedure in the acute care setting is not medically necessary for this enrollee. Care is covered by hospital's outpatient surgery fee, which includes overnight stay after the surgery. The performing provider can contact the health plan if the member requires a longer stay at the hospital after the surgery is completed. The FDA does not delineate any length of stay criteria. The review has determined that the items/services at issue in this case are 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 inpatient hospitalization for airway sizing and insertion of bronchial valve have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospitalization for airway sizing and insertion of bronchial valve.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 7, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to the hospital but it was not by choice. 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 $110 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $110 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 September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve podiatry services. You say that this was a follow-up appointment. You say this is the closest doctor.The Plan denied your request. The Plan says that you have been approved to go to in network providers .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 care that cannot be provided by network providers.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 podiatry services to be provided by an out of network (OON) provider.
Appeal type: Lab
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 October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 October 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) of the thorax (71250).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found a lung nodule was observed on imaging since 2015 and follow-up imaging including CT scans document no significant growth or change of this nodule. Stable nodules for more than 2 years would be considering not concerning and do not require any further imaging. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the thorax (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 3, 2019 through October 5, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that your heart rate dropped to 28 and that you were never told by your doctor not to take your propranolol medication, which caused a longer stay at the hospital. You state that your $390 copayment should be waived due to medical negligence and that it should have been scheduled at an outpatient facility at a lower cost.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 shows that you were admitted on October 3, 2019 and discharged on October 5, 2019. You were asked to pay a $190 copayment per day from October 3, 2019 through October 4, 2019, days 1-2 of your inpatient hospital care. You were discharged on October 5, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $195 copayment per day required for days 1-7. 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 from October 3, 2019 through October 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for destruction of lesions (17000) and an office visit (99215) provided on October 28, 2019.You asked the Plan to pay for the dermatology services. You say that you would like reconsideration and an explanation of the denied claim. The Plan denied your request. The Plan says these services were rendered by a provider who has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by OoN provider. This provider has opted out of the Medicare program. The file shows that provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for destruction of lesions (17000) and an office visit (99215) provided on October 28, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from July 22, 2019 through July 23, 2019 provided by an in-network provider.
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 due to the quality of care. 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 shows that you were admitted on July 22, 2019 and discharged on July 23, 2019. You were asked to pay a $295 copayment for July 22, 2019, days 1 of your inpatient hospital care. You were discharged on July 23, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $295 copayment per day required for days 1-5 of in-network 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 from July 22, 2019 through July 23, 2019 provided by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued rental of an Inogen portable oxygen concentrator to be provided by an out of network provider, Inogen.
You asked the Plan to pre-approve continued rental of an Inogen portable oxygen concentrator. You say that you have the Inogen portable oxygen concentrator from a previous health plan and want to continue to use it. The Plan denied your request. The Plan says they have in-network providers who supply portable oxygen.
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 care that cannot be provided by network providers. 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 continued rental of an Inogen portable oxygen concentrator to be provided by an out of network provider, Inogen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 24, 2019, 2019 through September 26, 2019 provided by an in-network provider.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 due to the quality of care.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 shows that you were admitted on September 24, 2019 and discharged on September 26, 2019. You were asked to pay a $295 copayment per day from September 24, 2019 through September 25, 2019, days 1-2 of your inpatient hospital care. You were discharged on September 26, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $295 copayment per day required for days 1-6 for in-network 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 from September 24, 2019, 2019 through September 26, 2019 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 9, 2018 through August 10, 2018.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the $500 cost-share is an erroneous charge considering your return to the provider was caused by a complication of an approved surgery performed at the facility and a delayed response to your request for help from the physician's office. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 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 from August 9, 2018 through August 10, 2018. You are asked to pay a $500 copayment for 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 from August 9, 2018 through August 10, 2018.