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

We decided that the Plan does not have to waive the copayment for a spinal canal injection provided on February 17, 2020.You asked the Plan to waive the copayment fora spinal canal injection. You say that you disagree with the 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.You received a spinal canal injection on February 17, 2020 at an outpatient hospital facility. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.  You have been asked to pay a $295 copayment for a spinal canal injection. A spinal canal injection falls within the outpatient surgery and other medical 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 spinal canal injection provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 13, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because the documentation does not include a valid physician order, lab requisition, or medical records
stating exactly which tests were 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 valid physician
order or clear intent to order the specific lab services billed on this claim. Based on this information, we
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing provided on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from August 16, 2019 through August 26, 2019. You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post-stabilization care. Our physician reviewer found the review has determined that the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission level of care services after the emergency room evaluation on August 16, 2019. There was no documentation provided necessitating post-stabilization care services beginning August 16, 201 at the non-Plan facility. The post-stabilization care services were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from August 16, 2019 through August 26, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the duplex extremity study rendered on January 17, 2020. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that procedure code 93970-TC was billed with an inappropriate modifier. 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 rules say that codes with a PC/TC indicator of 1 can be billed with modifiers 26 and TC. 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 states that procedure code 93970-TC was billed with an inappropriate modifier. This code has a PC/TC indicator of 1 and therefore can be billed with the TC modifier. The Plan has not provided any further documentation, explanation, or Medicare rules to support that the code is not payable as billed. Therefore, we decided that the Plan has to pay for the duplex extremity study rendered on January 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided from January 8, 2020 to March 9, 2020.
You asked the Plan to pay for the wound care supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization from the non-contracted supplier was not requested.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an enrollee. Records show that the wound care supplies was used in a SNF. Therefore, we decided that the Plan does not have to pay for the wound care supplies provided from January 8, 2020 to March 9, 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 the requested IRF admission is medically necessary. The Plan denied your request. The Plan says the requested IRF care is not considered medically reasonable and necessary.
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 enrollee was admitted on 6/13/2020 status post a sub-trochanteric, left femur fracture. The enrollee's course has included operative management; now at touchdown weight bearing. Pain control is appropriate, and working well. The enrollee is non-toxic and able to make needs known. There is no sign/symptom of toxicity, and functionally he is minimal assist at best, for transfers, but function varies depending on fatigue level. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. 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 does not require services at the LTACH that are not already available and being received at the current acute care facility or that would be available at a skilled nursing facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary, based on the provided records.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 5, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you requested that your girlfriend take you but were told that it was too dangerous. 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on February 27, 2020.
You asked the Plan to pay for the dental services. You say that you received an inadequate cleaning and you called the plan twice and were told there was no cleaning claim submitted for that date of service and that you could get another cleaning. The Plan denied your request. The Plan says there are no phone calls provided after request regarding misinformation.
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. You exhausted your benefit frequency limit, because you had this same service on February 5, 2020. Your EOC states, "Comprehensive Oral Exam (including the initial dental history and charting of teeth) covered once every 36 months". Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided March 8, 2019.
You asked the Plan to pay for the dental services. You say that you were told in 2019 the benefit was $650 whether the provider was in network or not. The guide does not say there is no dental coverage for non-Medicare dental providers. The Plan denied your request. The Plan says dental services provided by a provider who has formally 'opted out' of the Medicare program are not covered or payable by the plan.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the dental services provided March 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inpatient Mental Health services.You asked the Plan to pre-approve Inpatient Mental Health services. You say that the inpatient level care is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 Inpatient Mental Health services. Our reviewer says that the inpatient mental health services are not medically necessary. Our physician reviewer found insufficient medical records were provided to support that the enrollee's needs cannot be met in an outpatient 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 Inpatient Mental Health services have not been met.Therefore, we decided that the Plan does not have to pre-approve Inpatient Mental Health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274) and intraoral - periapical first radiographic image (D0220) provided on January 28, 2020 by an in-network provider.
You asked the Plan to pay for the dental services. You say that the provider did not use the correct codes. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. The Plan states you are not enrolled in the comprehensive dental rider.
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 for bitewings - four radiographic images (D0274) and intraoral - periapical first radiographic image (D0220) provided on January 28, 2020 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for prosthetic devices and related supplies provided on February 17, 2020.You asked the Plan to waive the coinsurance for prosthetic devices and related supplies. You say that you have never been charged in the past and disagree with the 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 20% coinsurance for prosthetic devices and related supplies. You received prosthetic devices and related supplies on February 17, 2020. The total allowed amount is $1,235.20 and 20% of that is $247.04. You have been asked to pay the total coinsurance amount of $247.04 for prosthetic devices and related supplies. Prosthetic devices and related supplies fall within the prosthetic devices and related 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 coinsurance for prosthetic devices and related supplies provided on February 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided January 15 to January 18, 2020.You asked the Plan to pay foracute inpatient hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says that coverage criteria was not met.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 are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 January 15 to January 18, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a roundabout power scooter.You asked the Plan to pre-approve a roundabout power scooter. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the roundabout power scooter you are requesting is no longer manufactured. The Plan says that you also currently have a GoGo scooter.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a GoGo scooter. A GoGo scooter serves the same purpose as a roundabout power scooter.Therefore, we decided that the Plan does not have to pre-approve a roundabout power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 25, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that the visit should be considered a follow-up visit and you disagree with the 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 $35 copayment per specialist visit. You had a specialist visit on November 25, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $25.53, which is less than the $35 copayment. You have been asked to pay $25.53 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 November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Powered Mobility Device (E1399).
You asked the Plan to pre-approve the Powered Mobility Device. You say that the Powered Mobility Device is
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 Powered Mobility Device. Our
reviewer says that the Powered Mobility Device is not medically necessary. Our physician reviewer found
there is no documentation that the enrollee has a mobility limitation that significantly impairs her ability to
participate in one or more mobility related activities of daily living (MRADLs). There is no documentation that
the mobility limitation is not sufficiently and safely resolvable by the use of an appropriately fitted cane or
walker. There is no documentation that the enrollee has had a specialty evaluation that was performed by a
licensed/certified medical professional documenting the medical necessity for the POV and its special features
for use within the home. 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 Powered Mobility Device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Powered Mobility Device (E1399).