Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you a total of $2,608 for hearing aids and a charger
provided on June 22, 2019.
You asked the Plan to reimburse you a total of $2,608 for the hearing aids and a charger. The Plan denied your
request. The Plan says the hearing aids have been reimbursed appropriately based on the benefits. A charger is
not a covered benefit. The enrollee is responsible for the cost of accessories and taxes for those accessories.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan has reimbursed you the appropriate
amount for the hearing aids based on your benefit. You are responsible for the cost of the charger. Therefore,
we decided that the Plan does not have to reimburse you a total of $2,608 for hearing aids and a charger
provided on June 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forgenetic testing services provided to "the beneficiary" on June 13, 2019.You asked the Planto pay forthe services. You say that payment should not be withheld because the ordering physician has not submitted the original notes.The Plandenied your request. The Plansaysprogress notes need to be submitted in order to determine the clinical utility of the testing.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 services at issue in this case were not medically reasonable or necessary. Our physician reviewer found in the case of this enrollee, various gynecological testing was performed on 6/13/2019, including genetic testing. However, the only clinical history provided was a diagnosis code (Z01.419) for encounter for a gynecological examination for routine purpose, which is not specific enough to determine the indication for the genetic testing. There was no other clinical information provided to help support this request. Therefore, the requested service will be considered not medically 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 the services have not been met.Therefore, we decided that the Plandoes not haveto pay forgenetic testing services provided to "the beneficiary" on June 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forinpatient hospital care provided to the enrollee from June 21, 2019 to June 22, 2019.You asked the Planto pay foracute inpatient hospital care. You say that the documentation should be reviewed and approved based on medical necessity.The Plandenied your request. The Plansaysthe notes did not show a medical need for inpatient admission.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 leasttwo midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found according to the records provided, the enrollee did not require a hospital stay. The hematoma which was separate from the fistula on her left arm was noted, but no procedure or treatment overall was warranted in a hospital environment. Although dialysiswas needed and appropriate to be completed in the hospital under the circumstances, this could have been completed and the enrollee discharged in less than a two-midnight stay. There was no indications from the provided records at the time of admission other than dialysis to warrant admission status.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 not been met.Therefore, we decided that the Plandoes not haveto pay forinpatient hospital care provided to the enrollee from June 21, 2019 to June 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe definitive drug testing provided on April 9, 2019.You asked the Planto pay forthe definitive drug testing. You say that this should be covered as it was medically necessary.The Plandenied your request. The Plansaysthe reported POS code of 81 is not supported based on the documentation.The Plan must follow Medicare rules. Medicare rules say that the POS code of lab claims must reflect the location that the specimen was collected. POS 81 is used when the sample is collected by the lab itself. In this case, the sample was collected on April 9, 2019 and received by the lab on April 11, 2019. This does not support a POS code of 81 as the sample was collected in the office setting.Therefore, we decided that the Plandoes not haveto pay forthe definitive drug testing provided on April 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound debridement provided on June 25, 2019, July 2, 2019 and July 9, 2019.You asked the Plan to waive the copayments forwound debridement. Yousubmitted your bills for review. You say that you don't understand why a copayment would be $360.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 $465 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.You have been asked to pay $360.48, which is less than the standard $465 copayment for each wound debridement visit. The total amount you owe is $1,081.44 ($360.48/visit x 3 visits = $1,081.44). Wound debridement 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 copayments forwound debridement provided on June 25, 2019, July 2, 2019 and July 9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on November 16, 2018.
You asked the Plan to pay for train of four testing. You say that the records support this code. The Plan denied your request. The Plan says the documentation indicates that Train of Four testing /Monitoring was performed which does not meet CMS guidelines for CPT code 95999.
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 code 95999 is not supported in the medical record. Specifically, unlisted CPT code 95999 is not supported for train of four testing. According to CPT rules, train of four is included in other intraoperative neuromonitoring procedures and is not reported separately. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on November 16, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gammaCore non-invasive vagus nerve stimulator.
You asked the Plan to pre-approve gammaCore non-invasive vagus nerve stimulator (VNS). You say that other
treatments have been tried and you believe gammaCore non-invasive vagus nerve stimulator is the enrollee's
best option for treatment. The Plan denied your request. The Plan says studies have not shown the gammaCore
non-invasive vagus nerve stimulator to be effective for migraines.
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 gammaCore non-invasive vagus nerve
stimulator. Our reviewer says that the requested item is not considered medically reasonable and necessary in
this case. Our physician reviewer found the published evidence on the use of non-invasive/transcutaneous VNS
in migraine headaches is largely limited to studies by the device's manufacturer. The studies were primarily
done in patients with episodic migraine (which is a distinct condition from chronic migraine--which is the
diagnosis which the patient carries). Most of the initial studies were open label in and carried a high risk of
bias. In the PRESTO study (Tassoreli, et al., 2018) it should be noted that the study did not meet its primary
efficacy endpoint and had other methodological limitations that preclude conclusions on the overall
efficacy/utility of the technology for the acute treatment of migraines. Rather the current body of literature
suggests that there remains a need for further study of the efficacy of this therapy in the acute treatment of
migraine both to determine the overall efficacy of the therapy and the comparative efficacy of this treatment. In
as much the requested therapy would not be medically necessary at this time given the need for further study of
the technology.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of gammaCore non-invasive vagus nerve stimulator have not been met. Therefore,
we decided that the Plan does not have to pre-approve gammaCore non-invasive vagus nerve stimulator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that this is medically necessary for the enrollee.The Plan denied your request. The Plan says that it is not reasonable or necessary to receive inpatient SNF level therapy for a member who is functioning at their physical baseline.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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria forSNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered to "the beneficiary" by "the hospital" from July 16, 2019 to July 18, 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 the services were unauthorized post-stabilization.

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 these services. Our reviewer says that the enrollee was stable for transfers. Our physician reviewer found the enrollee presented to the emergency department (ED) after a fall with complaints of pain. She was positive for a urinary tract infection and chest x-ray was clear. She was admitted in stable condition for a sacral fracture and pain control. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. The services were post-stabilization and the enrollee could have been transferred to a network facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered to "the beneficiary" by "the hospital" from July 16, 2019 to July 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are not able to get yourself to the bathroom and are afraid you will fall out of bed and hurt yourself. The Plan denied your request. The Plan says that your pain is under good control with oral pain medications, and you have no skilled nursing needs that might require a SNF.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 17, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you were never charged in the past and 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 $45 copayment for a specialist visit. You have been asked to pay a $45 copaymentfor a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe medical services provided on May 20, 2019 by out of network (OON) provider, "the medical center". You asked the Planto pay forthe OON medical services. You say that this should be covered based on medical necessity.The Plandenied your request. The Plansaysthe services were non-emergent and no effort was made to obtain authorization to provide these out of network. As such, this denial is correct.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/servicesat 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 forthe medical services provided on May 20, 2019 by out of network (OON) provider, "the medical center".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe percutaneous left atrial appendage closure services provided from June 14, 2019 to June 15, 2019.You asked the Plan to pay forthe percutaneous left atrial appendage closure services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are missing required information.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.Review of the file shows that Percutaneous Left Atrial Appendage Closure (LLAC)claims are covered when provided as part of a clinical trial. Review of the file does not include the clinical trial number on the billed claim. Based on this information, we decided that Medicare rules for coverage of the percutaneous left atrial appendage closure services have not been met. Therefore, we decided that the Plan does not have to pay forthe percutaneous left atrial appendage closure services provided from June 14, 2019 to June 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 forthe medical services provided on June 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee from September 4, 2019 through September 10, 2019.You asked the Plan to pay forinpatient 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 pay for inpatient mental health care. Our physician reviewer found the health plan's denial of inpatient psychiatric services appears appropriate. This enrollee did not appear to require inpatient mental health treatment as he was not a danger to himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. This patient was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided, for the admission of this patient does not meet the criteria for acute inpatient mental health treatment as this patient was not shown to be a danger to himself or others but was without agitation or aggression without perceptual disturbance including auditory or visual hallucinations.
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 pay forinpatient mental health care provided to the enrollee from September 4, 2019 through September 10, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhas to pre-approvea CT scan of the abdomen/pelvis.You asked the Plan to pre-approvethe abdominal/pelvic CT scan. You say that this imaging is needed to determine the extent and origin of the disease.The Plan denied your request. The Plan says that there is no need for abdominal/pelvic imaging in this case.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 abdominal/pelvic CT scan. Our reviewer says that the requested imaging is considered medically reasonable and necessary. Our physicianreviewer found the enrollee has a frontal lobemass concerning for primary brain tumor or metastasis. The requested imaging is necessary for workup for occult malignancy.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 abdominal/pelvic CT scan have been met.Therefore, we decided that the Plan has to pre-approvea CT scan of the abdomen/pelvis.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (CPT Code 99233) provided on May 2, 2019.You asked the Plan to pay for the services. You say that this should be considered emergency care as it was following an emergency room visit for the fractured hip.The Plan denied your request. The Plan says this service is not approved for coverage.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. Coverage cannot be provided for inpatient physician services, evaluation and management of patient rendered during a medical rehabilitation admission rendered May 2, 2019.Therefore, we decided that the Plan does not have to pay forsubsequent hospital care (CPT Code 99233) provided on May 2, 2019.