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

We decided that the Plan does not have to waive the coinsurance foroutpatient surgery services provided on November 19, 2019.You asked the Plan to waive the coinsurance foroutpatient surgery services. You say that you were informed that the services would be considered inpatient and disagree with the charges.The Plan denied your request.The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.The enrollee received outpatient surgery services on November 19, 2019. The record shows that the enrollee did not meet the criteria to be admitted inpatient. Therefore, the enrollee is responsible to pay $5,268.12, which is less than the 20% coinsurance amount. The enrollee has been asked to pay $5,268.12 for outpatientsurgery services. Outpatient surgery services fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 coinsurance foroutpatient surgery services provided on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient visit provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that the referring provider is out-of-network. The Plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an outpatient visit provided on January 9, 2020 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 services provided on November 26, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified. 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 documentation of the ordering
physician's intent that the tests 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 November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on December 10, 2019.
You asked the Plan to pay for the medical nutrition therapy. 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 medical nutrition therapy provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the determination of a refractive state (92015) provided on January 29, 2020.You asked the Plan to pay for the determination of a refractive state. Your appeal argument has not been included in the file. The Plan denied your request. The Plan says that eye refractions are only covered by your plan when performed by a participating provider and performed as a routine screening.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 forward your appeal request. Without your appeal request, we are unable to verify what services you are appealing and why.Therefore, we decided that the Plan has to pay for the determination of a refractive state (92015) provided on January 29, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 31, 2019. You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation hospital stay
provided from August 17, 2019 to August 24, 2019.
You asked the Plan to waive the copayment for the inpatient rehabilitation hospital stay. You say that this
should be processed under the skilled nursing facility benefit. 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 $289
copayment per day, days 1 to 6 at an in-network inpatient hospital.
You have been asked to pay a $289 copayment for each day, for three days of the inpatient rehabilitation
hospital stay. ($289 x 3 = $867). The inpatient rehabilitation hospital stay falls within the "Inpatient hospital
care" benefit category. The record shows this hospital is considered a rehabilitation hospital.
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 inpatient rehabilitation hospital stay provided from
August 17, 2019 to August 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on February 13, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
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 2020 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 a pump with an oxygenator or heat exchanger (99190) provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0482)
provided to the enrollee on November 20, 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 according to the claims data available at the time of the review, the plan was unable to discover
any evidence of an established relationship between the member and the ordering physician.
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 are:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service
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.
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 no records related to the
date of service in question have been submitted for review. Therefore, there is no evidence to support that the
service was properly ordered, provided, medically necessary or reasonable.
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 (CPT 80307 and HCPCS G0482) provided to the enrollee on November
20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cerebral spinal fluid shunt procedure
provided on February 5, 2019.
You asked the Plan to waive the copayment for the cerebral spinal fluid shunt procedure. You say that you are
disputing this claim and you feel there is no justification for the claim. 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 $50
copayment for each Medicare-covered in-network outpatient hospital facility or in-network ambulatory surgical
center visit for surgery.
You have been asked to pay a $50 copayment for the cerebral spinal fluid shunt procedure. The cerebral spinal
fluid shunt procedure falls within the "Outpatient surgery, including services provided at hospital outpatient
facilities and ambulatory surgical centers" 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 cerebral spinal fluid shunt procedure provided on February 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on April 3, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the original visit was cancelled. You say that you should not be charged. 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 $45 copayment per visit to a specialist. You have been asked to pay a $45 copayment for the office visit. The office 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 the office visit provided on April 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are having a lot of pain after neck surgery and would benefit from intensive rehab. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your condition, you don't meet the requirements.
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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the provided medical records do not document that the complexity of the patient's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelongterm acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria fortransfer 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 the enrollee is currently receiving appropriate care at the current acute care facility.  There was insufficient evidence provided suggesting she would need at least anadditional 25 days or more of acute care. The enrollee does not require any services at the LTACH that are not already available at the current acute care facility. Medicare coverage criteria 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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe proton beam therapy rendered from December 9, 2019 to December 18, 2019.You asked the Plan to pay forthese services. You say that the enrollee was on an approved clinical trial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Original Medicare is responsible for the costs associated with clinical trials.We looked at the file and Medicare rules. The file shows that the services at issue were rendered as part of a clinical trial. The claim for these services should be submitted to Original Medicare.Therefore, we decided that the Plan does not have to payforthe proton beam therapy rendered from December 9, 2019 to December 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ER visit and the replacement of a catheter provided from December 27, 2019 to December 31, 2019.
You asked the Plan to waive the copayments for an ER visit and the replacement of a catheter. You say that you had to keep returning to the ER and disagree with the multiple charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for ER visits. Your contract with the Plan also clearly says that you must pay a $295 copayment for outpatient hospital surgery. You had an ER visit provided on December 27, 2019. Therefore, you are responsible to pay the $90 copayment. You received the replacement of a catheter on December 31, 2019. Therefore, you are responsible to pay the $295 copayment. The total amount you owe is: $385. You have been asked to pay the total copayment amount of $385 for an ER visit and the replacement of a catheter. An ER visit and the replacement of a catheter falls within the outpatient hospital 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. Therefore, we decided that the Plan does not have to waive the copayments for an ER visit and the replacement of a catheter provided from December 27, 2019 to December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria for IRF level care has not been met.
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 not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided there is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Continued care in the acute hospital appears to be more appropriate until his feeding and anti-coagulation treatment are clarified. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 4, 2020 by a noncontracted
provider.
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 services were rendered by a non-contracted provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 4, 2020
by a non-contracted provider.