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

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 5, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because this was a follow-up visit. 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 $50 copayment for specialist visits.  
 
You had a specialist visit on March 5, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $50 copayment.  
 
You have been asked to pay a $50 copayment for 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 for a specialist visit provided on March 5, 2020.
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 enrollee needs daily physician visits, wound care, and wound care. The Plan denied your request. The Plan says the enrollee does not require complex wound management, and an LTACH does not provide clinical advantage over an acute care hospital. 
 
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include intermittent BiPAP, surveillance laboratory studies, total parenteral nutrition, fluid balance, glucose control, wound care, and therapy services. 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. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee beginning May 28, 2020.You asked the Plan to pre-approve SNF services. You say that the enrollee requires more care.The Plan denied your request. The Plan says that the enrollee does not meet criteria.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 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 for the enrollee beginning May 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on March 6, 2020.
You asked the Plan to waive the copayment for the endoscopy. You say that you were informed you didn't have to pay anything. 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 a $225 copayment for each Medicare-covered visit to an ambulatory surgical center. You have been asked to pay a $225 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The endoscopy is considered a surgical procedure. 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 endoscopy provided on March 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for occupational therapy provided from February 13, 2020 through March 3, 2020.You asked the Plan to waive the deductible for occupational therapy. You say that you don't recall being there four times. You say that they kept postponing appointments.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Outpatient rehabilitation is not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time occupational therapy was received from February 13, 2020 to March 3, 2020. Therefore, we decided that the Plan does not have to waive the deductible for occupational therapy provided from February 13, 2020 through March 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee does not require daily skilled therapy or daily wound care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that the enrollee received oral medications and had stable vital signs. He had a wound vac to his stump which was changed three times per week. He was treated for pain with effect. He was treated for hypokalemia. Regarding rehab services, he is at a minimal to maximal assist level with bed mobility and transfers. He requires varying assist with activities of daily living. Although there are identifiable skilled nursing and therapy service needs, the enrollee does not require skilled services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from January 7, 2019 through January 13, 2020 and January 28, 2020 through February 5, 2020.You asked the Plan to pay for SNF 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 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 SNF care. 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. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from January 7, 2019 through January 13, 2020 and January 28, 2020 through February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordialysis provided from January 3, 2020 to March 30, 2020.You asked the Plan to waive the coinsurance fordialysis. You say that you cannot afford the charges and thought that the services would be fully covered.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 dialysis treatments.You received dialysis from January 3, 2020 to March 30, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The total amount you owe is: $2,783.82.You have been asked to pay the totalcoinsuranceamount of $2,783.82for dialysis. Dialysis falls within the services to treat kidney disease 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 coinsurance fordialysis provided from January 3, 2020 to March 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hand controls (attachments to the steering wheel of your car) purchased on January 3, 2020.You asked the Plan to pay for the hand controls. You say that the hand controls are required for you to continue to function independently.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pay for hand controls (attachments to the steering wheel of your car) purchased on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a home ventilator (trilogy ventilator).
You asked the Plan to pre-approve ventilator. You say that without use of this device, the enrollee faces serious life-threatening conditions. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this ventilator exceeds the enrollee's needs and the enrollee can use a bi-level positive airway pressure (BiPAP) device instead.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested ventilator. Our physician reviewer found the enrollee may have chronic obstructive pulmonary disease (COPD), but it is not severe enough to be the most important cause of the hypoventilation. The enrollee is currently using a home ventilator as a bi-level positive airway pressure (BiPAP) device, which is not covered by Medicare. It appears the enrollee's needs can be met using a BiPAP. Certain BiPAP devices are capable of providing the noninvasive auto-titrating ventilation (AVAPS-AE) mode of support, if considered necessary. The records do not provide evidence of BiPAP failure. A home ventilator is 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of a home ventilator (trilogy ventilator).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan or waive the coinsurance for the insulin injection and saline infusions provided on March 18, 2020. 
 
You asked the Plan to waive the copayment for the CT scan and waive the coinsurance for the insulin injection and saline infusions. You say that you were not told about possible extra charges. The Plan denied your request. The Plan says that you pay the cost-sharing amounts for outpatient hospital services. 
 
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 $150 copayment for each advanced imaging service and a 20% coinsurance for Part B drugs.  
 
You have been asked to pay a $150 copayment for the CT scan and a 20% coinsurance for the insulin injection and saline infusions. The CT scan falls within the advanced imaging service benefit category and the insulin injection and saline infusions fall within the Part B drugs 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 CT scan and waive the coinsurance for the insulin injection and saline infusions provided on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcore buildup, including any pins when required (D2950), crown -porcelain/ceramic (D2740) and protective restoration (D2940) provided on February 26, 2020.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under the 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.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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forcore buildup, including any pins when required (D2950), crown -porcelain/ceramic (D2740) and protective restoration (D2940) provided on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a complete physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. 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 drug testing services provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay formedical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (CPT Code 97802) provided to the enrollee on February 6,2020.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says this service is not covered under Medicare or the Health Plan.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. Medical nutrition therapy (MNT) is covered by Medicare only for diabetes and renal disease, or for non-functioning structures that normally permit food to reach the stomach and digestive tract. As a non-covered service it is not a benefit when ordered by either a contracted or a non-contracted provider.Therefore, we decided that the Plan does not have to pay formedical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (CPT Code 97802) provided to the enrollee on February 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on November 1, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99291 is not supported. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 30-74 minutes of critical care spent on the enrollee. 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 critical care services rendered on November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services (HCPCS G0483) provided to the enrollee on December 12, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysHealthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugsand distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (anytype, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA,EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognizedinternal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3)method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variationsand mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or moredrug class(es), including metabolite."We asked our physician reviewer to carefully review the case file and apply the relevantMedicare 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 physician reviewer found the code at issue in this case requires certain criteria for appropriateness. No documentation has been provided to support the code.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 notbeen met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services (HCPCS G0483) provided to the enrollee on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe three line items with code J7999-KD for compounded drugs provided on September 18, 2019.You asked the Planto pay forthe compounded drugs as billed. You say that this should be paid as medically necessary refills for the enrollee's implanted infusion pump.The Plandenied your request. The Plansaysthis claim is not properly coded as only one unit of one line is to be reported for code J7999-KD with the specific drugs and amounts noted elsewhere on the claim.The Plan must follow Medicare rules. Medicare rules say that in order to bill for compounded drugs, providers must report one unit of J7999-KD on asingle line item. This claim reports multiple units of the J7999 code which is not correct billing based on the Medicare rules.Therefore, we decided that the Plandoes not haveto pay forthe three line items with code J7999-KD for compounded drugs provided on September 18, 2019.