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

We decided that the Plan has to waive the coinsurance for the dialysis treatments provided from January 3, 2020 to January 31, 2020.You asked the Plan to waive the coinsurance for the dialysis treatments. You say that you were not aware of the 20% coinsurance for the services. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were no Explanations of Benefit or claim forms showing the application of the coinsurance amount for the dialysis treatments. This means the plan has not shown that the coinsurance amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the coinsurance for dialysis treatments provided from January 3, 2020 to January 31, 2020.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that an exception is warranted due to the complexity of your condition. The Plan denied your request. The Plan says there are contracted providers who can do the services you need.
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 documentation shows that parenteral nutrition was requested. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
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 this transfer is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 documentation provided the enrollee is currently undergoing treatment at an acute care hospital (ACH) following scheduled cardiac surgery. Two weeks after surgery, the enrollee was intubated/ventilated and shortly thereafter he received a tracheotomy. It has not yet been established that adequate ventilator weaning attempts have failed. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. Medicare coverage criteria for transfer are not 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 4, 2020 through January 15, 2020.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.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 for the first three (3) days of the first five (5) days of your inpatient stay, dates of service January04, 2020through January 06, 2020, these were intensive care unit (ICU) room and board days and the allowed amount for the copayment was $1063.91. The remaining two (2) days of the first five days of your inpatient stay was for standard room and board and applied a copayment of $375.00 per day totaling of $750.00. Adding the copayment for three ICU room and board days along with the copayment for two standard room and board days, the patient responsibility is the allowed amount of $1,813.91 for days 1-5. 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 January 4, 2020 through January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy services for teeth #19 and 31.
You asked the Plan to pre-approve the dental services. You say that you have a bad infection from a needed
root canal. The Plan denied your request. The Plan says the service is not covered by your plan.
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.
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic
therapy services for teeth #19 and 31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that you are appealing the denial for the incontinence supplies.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither thePlan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve underpads (T4541).You asked the Plan to pre-approve the underpads. You say that the items are medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approve underpads (T4541).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSkilled Nursing Facility (SNF) services provided November 26 to December 26, 2019.You asked the Plan to pay forthe SNF services. You say that SNF services were medically necessary.The Plan denied your request. The Plan says rules for coverage were not met.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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as a practical matter this enrollee did not require the necessary services inpatient in a SNF. The enrollee's needs could have been met on an outpatient 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 the SNF services have not been met.Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services provided November 26 to December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99213) provided to the enrollee from November 12, 2019 to November 30, 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 the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated and exact duplicate claim/service.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 99213 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires two of these three key components:-An expanded problem focused history-An expanded problem focused examination-Medical decision making of low complexity Documentation to support this service should include, but is not limited to the following: Medicare allows only the medically necessary portion of the visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level of an E/M code."We asked our coding 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 coded correctly. Our coding reviewer found CPT 99213-24 billed for Date of Service November 12, 2019 on claim number 820200510280006 is a duplicate of the same service submitted by the same provider for the same date of service reflected in Claim number 820193170070031. The medical records submitted do not support providing this service more than once for November 12, 2019. CPT 99213-24 billed for November 23, 2019 and November 30, 2019 does not meet criteria for billing or reimbursement. The medical records provided do not indicated that the office visit (99213) performed on these two dates were for indications that were unrelated to surgical procedure 28285 that was performed on October 25, 2019 according to claim history submitted with this appeal, therefore these services cannot be verified. Procedure 28285 has a 90 day global surgical package, therefore, 99213 performed on November 23, 2019 and November 30, 2019 does not support the use of a 24 modifier.We looked at this coder'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 Plan does not have to pay for office visit services (CPT 99213) provided to the enrollee from November 12, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 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 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 June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure
code 81479.
The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant 360/NEXT-Generation molecular genetic pathology testing provided to the enrollee on March 3, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says service providers should use CPT 81479 at this time.
The Plan must follow Medicare rules. Medicare rules say that Guardant 360 testing must be reported with CPT 81479. The denied testing was not reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant 360/NEXT-Generation molecular genetic pathology testing provided to the enrollee on March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 24, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 subsequent nursing facility care provided on December 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on March 9, 2020.
You asked the Plan to waive the copayment for the eye exam. You say that you were unaware the doctor wasn't in network. You say that you shouldn't have to pay the specialist copayment. The Plan denied your request. The Plan says the copayment 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 $45 for each Medicare-covered outpatient visit for services to diagnose and/or treat a disease or condition of the eye. You have been asked to pay a $45 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that you were charged the in-network copayment for the eye exam. 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 eye exam provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on November 7, 2019by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says 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 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 foran office visit provided on November 7, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 20, 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 August 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET with CT imaging, provided on December 14, 2019.You asked the Plan to pay for the PET scan with CT imaging. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 did not pre-approve the servicesat 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 forthe PET with CT imaging, provided on December 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe transportation services provided on January 31, 2020.You asked the Plan to reimburse you forthe non-emergent taxi transportation services. You say that you did not have transportation back to home so the Plan should reimburse you.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 taxi transport services. The services you have asked the Plan to reimburse for are taxi transport services.Although you have a routine transportation benefit this transport was not scheduled, not coordinated through the Plan's transportation coordinator, and beyond the 30-mile limit.Therefore, we decided that the Plan does not have to reimburse you forthe transportation services provided on January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the breast
(77049).
You asked the Plan to pre-approve an MRI of the breast. 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. Medicare rules say that MRIs 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 an MRI of the breast. Our reviewer says
that the services are not medically necessary. Our physician reviewer found based on your initial diagnosis
mass, you have been getting screening MRIs. An MRI of the breasts was ordered as follow-up screening. An
annual MRI is recommended for women with a lifetime risk of greater than or equal to 20%. The
documentation is insufficient to demonstrate that an MRI of the breasts is medically reasonable and necessary
for you in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an MRI of the breast have not been met. Therefore, we decided that the Plan
does not have to pre-approve a magnetic resonance imaging (MRI) of the breast (77049).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvea continuous glucose monitor. You say that your fingers are sore from finger stick testing.The Plan denied your request. The Plan says you do not meet criteria for a CGM. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record shows you are not insulin treated three or more times a day and are not testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.