Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe colorectal screening services provided on April 30, 2019 by out of network provider.You asked the Plan to pay forthe colorectal screening services. You say that you would like the plan to reconsider their denial.The Plan denied your request. ThePlan says the services provided are not a covered benefit.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 colorectal screening services provided on April 30, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit and x-ray provided on July 25, 2019 and the office visit and arthrocentesis services provided on August 14, 2019.You asked the Plan to waive the deductible forthe office visits, x-ray, and arthrocentesis. You say that you would like the plan to reconsider their decision.The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.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 there is a $500 deductible that you must pay out-of-pocket before the plan will pay their share for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the deductible benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that you must pay out-of-pocket before the plan will pay their share for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time the office visits, x-ray, and arthrocentesis was received on July 25, 2019 to August 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe office visit and x-ray provided on July 25, 2019 and the office visit and arthrocentesis services provided on August 14, 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 on July 11, 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 the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 to the enrollee on July 11, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a tumor excision (25071) provided on July 9, 2019.
You asked the Plan to pay for the excision. You say that you would like reconsideration as this service has been billed correctly. The Plan denied your request. The Plan says this service has been billed with an incorrect place of 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. We find that CPT code 25071 is not supported in the record. Specifically, per the 2019 Physician Fee Schedule. CPT code 25071 has a Non-Facility indicator of NA. This means that this procedure is rarely or never performed in a non-facility setting. This service was billed with non-facility place of service 11. Based on this information, we decided that Medicare rules for coverage of the excision have not been met. Therefore, we decided that the Plan does not have to pay for a tumor excision (25071) provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 10, 2019 out of network. You asked the Plan to pay for out of network services. You say that this service should be covered.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 June 10, 2019 out of network provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a cortisone injection (20600 and J3301).You asked the Plan to pre-approvea cortisone injection (20600 and J3301). You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that theservices are denied due to lack of clinical records.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. Specifically, it is the plan's responsibility to show that its decision to deny coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases where the plan has not supplied records from a plan provider that are critical to its decision, we may properly find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plan's failure to obtain records that are within the plan's control.Therefore, we decided that the Plan has to pre-approvea cortisone injection (20600 and J3301).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan provided on August 20, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you should not have to pay the copayment because this CT scan is because of your injury in July. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $250 copayment per day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the CT scan.
You have been asked to pay a $136.44 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 provided on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on June 18, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on June 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from July 11, 2019 to August 31, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee requiredand received during the period in question are coverable under the Medicare Act.The Plan denied your request. The Plan says that Skilled Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days ina row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from January 29, 2019 to September 23, 2019. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from July 11, 2019 to August 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 14, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 physician's services provided on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage have 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 the MRI. Our reviewer says that coverage criteria has not been met. Our physician reviewer found office notes do not include follow-up notes, conservative measures, or differential diagnosis. Without the support of the documentation, medical necessity cannot be determined.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 MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the knee (73721).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from November 11, 2017 to January 9, 2018.
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 claims were not billed with a valid HHRG code.
The Plan must follow Medicare rules. Medicare rules say that on Medicare claims, HHRGs are represented as Health Insurance Prospective Payment System (HIPPS) codes. We looked at the file and Medicare rules. The home health claims were not billed with the required HIPPS code to represent the HHRG. 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 home health services rendered to the enrollee from November 11, 2017 to January 9, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Intensive Care Unit (ICU) services rendered September 9 to September 11, 2018.
You asked the Plan to pay for the ICU services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee required inpatient level care, but coverage rules for the ICU admission were not met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ICU services. Our reviewer says that the ICU level of care was not medically necessary. Our physician reviewer found based on the medical records provided the patient did require admission to the acute hospital but intensive care unit level services were not required. 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 ICU services have not been met. Therefore, we decided that the Plan does not have to pay for Intensive Care Unit (ICU) services rendered September 9 to September 11, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 26, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the breast with Computer Aided Detection (77049) provided July 25, 2019.You asked the Plan to pay forthe MRI. You say that the services were medically necessary.The Plan denied your request. The Plan says the code used on the submitted claim is not recognized by Medicare.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 77049 is not supported in the medical record. Specifically, code 77049 is not recognized by Medicare OPPS. There may be a more appropriate, recognized code for this service. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plan does not have to pay forMagnetic Resonance Imaging (MRI) of the breast with Computer Aided Detection (77049) provided July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat
exchanger (99190) provided on July 17, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say
that this service was mandatory per hospital protocol. The Plan denied your request. The Plan says payment of
this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190)
provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Botox injections provided from May 2, 2019 to October 22, 2019.
You asked the Plan to waive the coinsurance for Botox injections. You say that you paid the $50 copayments and disagree with the additional 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 15% coinsurance for Part B drugs that are administered by a provider. You received a Botox injection on May 2, 2019. The allowed amount is $275.40 and 15% of that is $41.31. You received a Botox injection on July 26, 2019. The allowed amount is $275.40 and 15% of that is $41.31. You received a Botox injection on October 22, 2019. The allowed amount is $1,224.00 and 15% of that is $183.60. The total amount you owe is: $266.22. You have been asked to pay the total coinsurance amount of $266.22 for Botox injections. Botox injections fall 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 for Botox injections provided from May 2, 2019 to October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from June 21, 2019 through June 24, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment aremet in this case. Our physician reviewer found the review has determined that 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 (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from June 21, 2019 through June 24, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1851) and suspension sleeve (L2397) provided September 4, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the services in dispute. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telemedicine and telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) knee orthosis (L1851) and suspension sleeve (L2397) provided September 4, 2019.