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

We decided that the Plan does not have to waive the copayment foran x-ray provided on January 8, 2020.You asked the Plan to waive the copayment foran x-ray. You say that you disagree with the charges because the X-ray was necessary.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 discloseto 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 non-Medicare covered x-ray services for chiropractic services. You have been asked to pay a $35 copayment for an x-ray. An x-ray falls within the chiropractic services 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 acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran x-ray provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on December 19, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that
the member's primary care physician did not refer 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 lab tests provided on December 19, 2019 by an out
of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support the need for daily therapy on an inpatient basis.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse the coinsurance for physician services provided from
December 6, 2019 to December 9, 2019.
You asked the Plan to reimburse the coinsurance for physician services. You say that you should be reimbursed
more than you were for the services. 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 20%
coinsurance for out-of-network physician/practitioner services, including doctor's office visits.
You received physician services from an out-of-network provider from December 6, 2019 to December 9,
2019. The total allowed amount is $1,857.43 and 20% of that is $371.44. Please contact the provider for any
questions regarding overpayment and refunds.
You have been asked to pay the coinsurance amount of $371.44 for physician services. Physician services fall
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 reimburse the coinsurance for physician services provided from December 6, 2019 to
December 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 18, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for podiatry visit. You say that your physician rendered services and should be
compensated. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this provider is out-of-network with the Plan and 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 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 medical services provided on December 18,
2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 3, 2019 to December 5, 2019.You asked the Plan to pay for the acute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says that that there were no complications that required 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 least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. Our physician reviewer found that your condition met Medicare criteria for the acute inpatient hospital care.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 acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 3, 2019 to December 5, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (A4550) provided on December 17, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee
Schedule indicates that payment for covered services are always bundled into payment for other services not
specified.
We looked at the file and Medicare rules. Procedure code A4550 is assigned a status indicator of "B" under the
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into
payment for other services. No separate payment can be made for the services. 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 the services (A4550) provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 31, 2019 to August 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skin debridements. You say that it is not your provider's responsibility to obtain authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 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 medical services provided on May 31, 2019 to August 30, 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 physician services provided on February 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. You say that these services were requested by a provider. The Plan denied your request. The Plan says the requesting provider is out-of-network. The Plan says that no prior authorization was 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 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 physician services provided on February 18, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic shrinker, above knee (L8460) prosthetic sock, multiple ply, above knee, (L8430) and prosthetic sock, single ply, above knee, (L8480).You asked the Plan to pre-approve the prosthesis accessories. You say that the enrollee is currently living in a skilled nursing facility and needs to have his prosthetic legs prior to being discharged from the skilled nursing facility.The Plan denied your request. The Plan says the cost of these items are included in the payment to the skilled nursing facility.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthesis accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve prosthetic shrinker, above knee (L8460) prosthetic sock, multiple ply, above knee, (L8430) and prosthetic sock, single ply, above knee, (L8480).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that a power seat elevation
feature is medically necessary to facilitate sit to stand transfers and allow a higher reach. The Plan denied your
request. The Plan says a power seat elevation feature is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
A power seat elevation feature does not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay fora CT Scan of the head and brain (70450) provided on November 18, 2019.You asked the Plan to pay for the CT Scan. You say that you would like reconsideration as this code is payable.The Plan denied your request. The Plan says that CPT code 70450 is a column II code to CPT code 70496.The Plan must follow Medicare rules. Medicare rules say that MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT Scan have been met. Specifically, the record indicates that these services were rendered by providers with different NPIs.Therefore, we decided that the Plan has to pay fora CT Scan of the head and brain (70450) provided on November 18, 2019.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 waive the copayment for an inpatient hospital stay provided from February 23, 2017 to March 1, 2017.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 copayment per day for days 1-7 for inpatient hospital care. You had an inpatient hospital stay from February 23, 2017 to March 1, 2017. Therefore, you are responsible to pay a $260 copayment for day 1-6 (February 23, 2017 to February 29, 2017). $260 (copayment) x 6 (inpatient days) = $1,560.00. You have been asked to pay the total copayment amount of $1,560.00 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from February 23, 2017 to March 1, 2017.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the provided medical records the enrollee is receiving necessary services in the present acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as a skilled nursing facility or home with home health services if needed. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ground ambulance services. You say that on the date of service you were cutting a tree limb when you fell from the ladder. You say that you were knocked unconscious and had bleeding from a cut on your head and ears. Your family called 911 and the ambulance responders treated you and determined that you needed to be air lifted to the hospital. You say that you were unaware of what was happening and were unable to correctly answer questions. You stated that at the hospital it was discovered that you had a skull fracture and a hemorrhage. You say that you do not understand why the ambulance claim is being denied since the responders came and provided care before you were turned over to the air ambulance crew. You asked the Plan to reconsider their denial. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ground ambulance company did not provide transport services on January 25, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says the requested LTACH care is not considered medically reasonable and necessary in this case.
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 admitted to the acute care hospital on 5/25/20 with acute respiratory failure and stroke. His past medical history is notable for diabetes, hypertension, stroke, and dementia. The enrollee was extubated on 6/3/20. A PEG tube has been placed, and the enrollee is NPO. Antibiotics are being administered for pneumonia. On 6/17/20, it is documented that the enrollee's prognosis is poor, and that the physician agrees with consideration being given to hospice. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The clinical assessment does not support that the enrollee is likely to benefit from, and improve with LTACH care. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body and placement of a custom abutment provided to the enrollee from July 25, 2019 to October 31, 2019.You asked the Plan to pay for these services. The Plan denied your request. The Plan says that they will not pay to restore a congenitally missing tooth.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body and placement of a custom abutment provided to the enrollee from July 25, 2019 to October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Neck (70491).
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 coverage criteria has 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 CT scan is not medically necessary at this time. Our physician reviewer found the provided records to not substantiate the need for a CT scan of the neck. 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 Neck (70491).