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

We decided that the Plan does not have to pay for the medical services provided the enrollee by an out-of-network provider on August 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided the enrollee by an out-of-network provider on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care provided on September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that authorization should have been the responsibility of the facility and these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
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 nursing facility care provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says that that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is found to be medically reasonable and necessary for this enrollee. The member has therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet his rehabilitation needs. Our physician reviewer found that the enrollee's condition meets Medicare criteria for IRF 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal epidural injection (64483
and 64484).
You asked the Plan to pre-approve a lumbar/sacral transforaminal epidural injection (64483 and 64484). You
say that the requested lumbar/sacral transforaminal epidural injection is medically necessary. The Plan denied
your request. The Plan says the requested lumbar/sacral transforminal epidural injection does not meet criteria.
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 a lumbar/sacral transforaminal epidural
injection (64483 and 64484). Our reviewer says that the requested lumbar/sacral transforminal epidural
injection does not meet criteria. Our physician reviewer found the enrollee is with a diagnosis of connective
tissue and disc stenosis of intervertebral lumbar disc region. Criteria for lumbar injection have not been met.
There is no documentation of functional improvement after previous injection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a lumbar/sacral transforaminal epidural injection (64483 and 64484) have not
been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral transforaminal
epidural injection (64483 and 64484).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for urgent care services provided on October 13, 2019.
You asked the Plan to waive the copayments for urgent care services. You say that you should not be charged separate cost-sharing for both the physician and facility. The Plan denied your request. The Plan says that the cost-sharing amounts you are being charged are correct.
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. The Plan did not provide a copy of the applicable Evidence of Coverage document for this date of service. Without this information, we cannot determine whether the cost-sharing amounts you have been asked to pay are correct or justified based on the Plan contract. Therefore, we decided that the Plan has to waive the copayments for urgent care services provided on October 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided to the enrollee on August 15,
2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of
testing. The physicians order and the medical records must specifically show how this testing will be used to
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we
decided that the Plan does not have to pay for drug testing (G0483) provided to the enrollee on August 15,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September
11, 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 Current Procedural Terminology (CPT) code 80307 and Healthcare Common Procedure Coding
System (HCPCS) G0483 remain 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 the denied codes is:
HCPCS G0482:
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms
(any type, 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
recognized internal 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 variations and mass spectral drift); qualitative or quantitative, all sources, includes
specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed
CPT 80307:
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service
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 coded correctly. Our physician reviewer found an order for toxicology
screening was signed. No medical records documenting prescribed medications, previous drug testing or
modifications to therapy were submitted. No specific rationale for the testing was submitted. The records do
not support the coding of CPT 80307 and HCPCS G0482.
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 Plan does not
have to pay for drug testing services provided to the enrollee on September 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for custodial care services provided from July 30, 2019 to September 7, 2019.
You asked the Plan to pay for custodial care visits. You say that you needed these services and the plan that you have covers home health care services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services were custodial care in nature which is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that custodial care services are not covered by Medicare. We looked at the file and Medicare rules. The record shows that the services provided were custodial care in nature, therefore these charges are not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of custodial care visits have not been met. Therefore, we decided that the Plan does not have to pay for custodial care services provided from July 30, 2019 to September 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist services rendered to you on July 23, 2019 to July 31, 2019.
You asked the Plan to waive the copayments for these services. You say that the services should be considered post-operative visits. The Plan denied your request. The Plan says the copayments were 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 $20 copayment for specialty physician services.
Review of the file shows that you received specialty physician services on July 23, 2019; July 26, 2019; and July 31, 2019. You have been asked to pay a $20 copayment per date of service for these services, for a total of $60. These services fall within the specialty physician 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 a contractual obligation you agreed to pay when you enrolled in the Plan. Payment for these services is not included in the global surgical package because the file shows that you received diagnostic urine testing performed, and diagnostic testing is not included in the surgical payment.
Therefore, we decided that the Plan does not have to waive the copayments for the specialist services rendered to you on July 23, 2019 to July 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that you need another trip for dialysis. The Plan denied your request. The Plan says your plan only allows 24 trips.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on the information provided, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from August 20, 2019 to August 24, 2019.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that the correct copayment has been applied to the inpatient hospital care provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $465 copayment for each Medicare-covered day, for days 1-4 for inpatient hospital care. The enrollee has been asked to pay a $1,860 copayment ($465 x 4 days) for inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided August 20, 2019 to August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Neulasta injection provided on October 7, 2019.You asked the Plan to waive the coinsurance forthe Neulasta injection. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a Neulasta injection on the date of service at issue in this appeal. The Plan statesthe correct coinsurance has applied per your contract with the Plan.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 10% coinsurance for Medicare Part B prescription drugs. We looked at the file, the Plan contract and Medicare rules. The file shows you received a Neulasta injection on October 7, 2019. You have been asked to pay a 10% coinsurance for the Neulasta injection, totaling $491.90. The Neulasta injection falls within the Medicare Part B prescription 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 coinsurance forthe Neulasta injection provided on October 7, 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 the SNF services. You say that the clinical information provided supports the medical necessity of SNF care. The Plan denied your request. The Plan says SNF services are not medically reasonable and 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. The enrollee received physical therapy, speech therapy, and occupational therapy I the skilled nursing facility. The enrollee was at moderate assist level for functional mobility, including gait to short distances. The enrollee required varying assist with activities of daily living. The enrollee tolerated a mechanical soft diet and thin liquids. The enrollee does not have an identifiable skilled therapy service needs. The enrollee does not have any identifiable skilled therapy service needs. The enrollee does not meet the 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 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: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pay forwheelchair van transport for the enrollee.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services.Therefore, we decided that the Plandoes not haveto pay forwheelchair van transport for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 13, 2019 by an out of network (OON) provider.You asked the Plan to pay for laboratory tests. You say that you are appealing with records.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 the ordering practitioner is also out-of-network with the Plan.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 November 13, 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 the medical services provided to you by an out-of-network provider on October 10, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 22, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on July 22, 2019.