Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 18, 2019 through November 18, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME from July 18, 2019 through November 18, 2019. You are asked to pay 20% coinsurance per date of service for the DME. 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 portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 18, 2019 through November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan.
You asked the Plan to pre-approve the FDG PET scan. You say that this is needed in order to determine the extent of the enrollee's disease. The Plan denied your request. The Plan says Medicare does not cover this imaging for initial treatment planning for prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that FDG PET scans are covered for initial treatment planning for certain cancers. However, this is not covered for this purpose for newly diagnosed prostate cancer. Therefore, we decided that the Plan does not have to pre-approve a fluorodeoxyglucose (FDG) positron emission tomography (PET) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extremity veins rendered to the enrollee on April 4, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 93970 was not billed correctly.
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis. We looked at the file and Medicare rules. The file shows that code 93970 was billed with two or more mismatched diagnosis codes. The billed diagnosis codes indicate laterality, which is not appropriate for code 93970. Therefore, we decided that the Plan does not have to pay for the duplex scan of extremity veins rendered to the enrollee on April 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from August 2, 2019 through August 4, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the stay was not medically necessary. The Plan denied your request. The Plan says the stay was medically necessary, as well as the length of stay. This is only an outpatient procedure when it is planned, and there aren't any active signs of inflammation/infection, of which you had both; the post-operative elevation of liver enzyme did warrant the continue stay.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received medically necessary inpatient hospital care from August 2, 2019 through August 4, 2019. You are asked to pay a $335 copayment per day from August 2, 2019 through August 3, 2019, days 1-2 of inpatient hospital care. You were discharged on August 4, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $335 copayment per day required for days 1-5. 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 inpatient hospital care provided from August 2, 2019 through August 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dofetilide.You asked the Plan to pre-approveDofetilide. You say that the medication will reduce the enrollee's risk of a cardiac episode.The Plan denied your request. The Plan says oral medications are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDofetilide.Benefits for Dofetilidemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional skilled nursing visits (total of 12) to be provided in the home.
You asked the Plan to pre-approve the 12 skilled nursing home visits. You say that the enrollee needs wound care services that cannot be provided by the assisted living facility staff. The Plan denied your request. The Plan says four skilled nursing visits will be sufficient to treat these wounds and that is all that will be approved at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 12 skilled nursing home visits. Our reviewer says that the documentation does not support that the 8 additional skilled nursing visits are medically reasonable and necessary. Our physician reviewer found on February 7, 2020, it was reported that the patient has open sores on the lower legs that need to be cleansed with saline and ammonium lactate lotion needs to be
applied to dry skin. The open areas need to be covered with calcium alginate and wrapped with gauze and secured with tape. Four visits were approved for this purpose. The records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the patient beyond what was approved by the health plan. The patient's wound's and wound care needs are not so complex that they require a skilled nurse for a total of 12 visits therefore the request for the remaining 8 non approved skilled nursing visits are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 12 skilled nursing home visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional skilled nursing visits (total of 12) to be provided in the home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 17, 2019.You asked the Plan to waive the copayment for the office visit. You say that you did not have surgery. You say that you should not be responsible for payment.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 $40 copayment for provider and professional services at an in-network specialist's office.You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was with a dermatologist, which is considered a specialist. 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 forthe office visit provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cortisone injection provided on July 19, 2019.
You asked the Plan to waive the copayment for the cortisone injection. You say that you did not have surgery, you received a cortisone shot. You say you received the shot at the doctor's office and not a clinic. 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 $200 copayment for each Medicare-covered in-network outpatient hospital facility visit. You have been asked to pay a $200 copayment for the cortisone injection. The cortisone injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows a cortisone shot is considered a surgical procedure. The record also shows you were billed by the 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 cortisone injection provided on July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on September 30, 2019 by
an out of network provider.
You asked the Plan to pay for an office visit. You are appealing the claim payment denial for services rendered
to the Plan's member on date of service September 30, 2019. The notes will support the need for service. The
Plan denied your request. The Plan says the rendering provider and rendering facility are non-participating providers. The plan did not authorize these services. There is no referring doctor on file. There are
multiple in-network providers within 30 miles of the member's residence that could have rendered the services.
The services were not considered urgent or emergent in nature.
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 office visit (99214) provided on September 30,
2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies coded 95910 and the needle electromyography services coded 95885 provided on November 14, 2018.
You asked the Plan to pay for the nerve conduction studies and the needle electromyography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 95910 and 95885 are not supported in the medical record. Specifically, the documentation does not support that nerve conduction studies, 7-8 studies were performed. Therefore, code 95910 cannot be verified. Also, the required primary service code (CPT 95910) is denied, therefore, code 95885 cannot be separately reimbursed. Based on this information, we decided that Medicare rules for coverage of the nerve conduction studies and the needle electromyography services have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies coded 95910 and the needle electromyography services coded 95885 provided on November 14, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an arthroplasty (27447) provided on July 22, 2019.You asked the Plan to pay for the arthroplasty. You say that the provider is a licensed surgical assistant in the state of Colorado. The Plan denied your request. The Plan says certified surgical technicians are not recognized for payment per Center for Medicare/Medicaid Services guidelines.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for an arthroplasty (27447) provided on July 22, 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 October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mohs surgery services provided on March 25, 2019 by the out of network provider.
You asked the Plan to pay for the Mohs surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received 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 for the Mohs surgery services provided on March 25, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (85610, 70551, 80053, 85025, 81001, 80307) provided on July 25, 2019 by an out of network provider.
You asked the Plan to pay for laboratory services. You say that the services were medically necessary. This procedure was an elective admission and therefore no notification or prior authorization was obtained. The Plan denied your request. The Plan says the enrollee had a routine blood test done by an out-of-network provider. The test was not emergent, and not authorized by 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 for laboratory services (85610, 70551, 80053, 85025, 81001, 80307) provided on July 25, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on May 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code Q9967 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code Q9967 is low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml. We find that CPT code Q9967 is not supported in the medical record. Specifically, there is no documentation that low osmolar contrast material, 300-399 mg/ml of iodine concentration was administered. 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 services rendered to the enrollee on May 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary until the enrollee's next doctor appointment. The Plan denied your request. The Plan says the enrollee is unlikely to make any additional improvement with skilled rehab services 5 to 6 times per week.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says screening tests are not covered.
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 test 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 services rendered on September 19, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the colonoscopy provided on October 9, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you were told the procedure was not routine and that you owe a $350 copayment. You say you cannot afford the copayment. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
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 record shows a screening colonoscopy was billed and no records were submitted to show that a biopsy or removal of a lesion or growth was performed. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the colonoscopy provided by on October 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on August 29,
2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says
there is no valid referral for this service.
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 a domiciliary or rest home visit provided on August 29, 2019.