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

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 25, 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 the records do not support the services billed.
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 the denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11) Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 does not require the intensity of services provided at an IRF. The enrollee has been making progress at his current location. The enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met at a lower level of 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe seat lift mechanism purchased on January 30, 2020.You asked the Plan to reimburse you forthe seat lift mechanism. You say that you now realize the correct provider was not used.The Plandenied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare.The Plan must follow Medicare rules. The rules say no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. We looked at the file and Medicare rules. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Basedon this information, we decided that Medicare rules for coverage of the seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to reimburse you forthe seat lift mechanism purchased on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on April 25, 2019.
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges because you were not charged in the past. 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. Your contract with the Plan says that there is a $700 deductible for physician/practitioner services, including doctor's office visits. You had an office visit on April 25, 2019. The record shows that you had only paid $18.42 toward the $700 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $121.37. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $700 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on April 25, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on April 25, 2019.
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 you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission is not medically necessary.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 undergoing treatment at an acute care hospital for shortness of breath, in the setting of tonsillar cancer and a chronic tracheotomy. The enrollee has received respiratory medications, pulmonary toilet, supplemental oxygen andintermittent BiPAP/CPAP. The enrollee is not on a ventilator and is not expected to be decannulated. There is no evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current acute care hospital until such time no acute services are required. Therefore, the enrollee does not meet criteria for the requested admission.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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology genomic profiling test provided to the enrollee on November 19, 2019. You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says this is an administrative determination for coding and is not based on medical necessity. 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 81405 and CPT 81406 are not supported in the medical record. Specifically, the test must be coded with CPT 81479, rather than CPT 81405 and CPT 81406. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the  molecular pathology genomic profiling test provided to the enrollee on November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound repair (12052) provided on June 22, 2019.
You asked the Plan to pay for wound repair. You say that this was coded correctly. The Plan denied your request. The Plan says there is a more appropriate code for the service performed.
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 12052 is repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm. 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 wound repair. Our reviewer says that this code is not supported in the records. Our physician reviewer found the medical records provided do not include documentation of a repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm being performed on June 22, 2019, therefore this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wound repair have not been met. Therefore, we decided that the Plan does not have to pay for wound repair (12052) provided on June 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 14, 2019 through October 16, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you were billed a larger copayment than expected. You say that an inpatient stay was not warranted.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 $300 copayment per day for days 1-5 for each in-network, Medicare covered inpatient hospital stays.You have been asked to pay a $600 copayment for the inpatient stay. ($300/day x 2 days = $600). The inpatient stay falls within the "Inpatient hospital care" benefit category. The records show that this was an inpatient stay. 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 stay provided from October 14, 2019 through October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy services provided from December 12, 2019 through December 31, 2019.
You asked the Plan to waive the copayment for radiation therapy services. You say that you were not informed of the copayment for each treatment. You say that the charges should be reversed. The Plan denied your request. The Plan says the copayments 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 $50 copayment for each Medicare-covered radiation therapy service. You have been asked to pay a $50 copayment for each radiation therapy service. The total amount you owe is $450 ($50/visit x 9 visits = $450). Radiation therapy services fall 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 radiation therapy services provided from December 12, 2019 through December 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from February 5, 2020 to February 10, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are appealing the inpatient services. 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 $295 copayment per day, days 1 to 6 for at an in-network inpatient hospital. You have been asked to pay a $295 copayment for each day, days 1-5 of the inpatient hospital stay. ($295 x 5 = $1,475). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from February 5, 2020 to February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 14, 2019.You asked the Plan to pay for the domiciliary, 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 service 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, rest home visit provided on November 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from February 25, 2019 to March 14, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you were told by the provider's office that you would not have a copayment. You say the provider advised they would not file to your insurance and this was a free service. 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 $40 copayment for each in-network visit for Medicare-covered occupational therapy, physical and/or speech language visits. You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation 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 the physical therapy visits provided from February 25, 2019 to March 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that the ambulance came to your house on the date of service because you had lost consciousness due to your sugar being too low. You say that you received treatment from the EMS responders to get your sugar levels back up and they left once you were feeling back to normal. You stated that you were told that the claim was billed incorrectly and you didn't owe the full amount. You say that you were told it was a coding error and you would only owe a copay but then the claim didn't get paid.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 19, 2018. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that that if the enrollee does not receive this level of care it will affect her ability to regain maximum function. The Plan denied your request. The Plan says based on Medicare guidelines, approval of an IRF admission does not meet the requirements for approval.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there is no indication that the enrollee's present condition requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lens tintprovided on August 19, 2019.You asked the Plan to pay forthe addition to lens (V2745). You say that the eyeglasses are covered so the claim should be paid.The Plan denied your request. The Plan says a corrected claim is needed because V2745 is missing the required modifier.The Plan must follow Medicare rules. The rules state thatproviders must bill services with a modifier if the service billed with the modifier indicates a distinct procedural service.Based on this information, we decided that Medicare rules for coverage of services billed without a modifier have not been met.Lens tint is not covered and therefore requiresthe EY modifier. Therefore, we decided that the Plan does not have to pay forthe lens tintprovided on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the knee brace provided on October 31, 2019.
You asked the Plan to waive the coinsurance for the knee brace. You say that you were informed that since the brace was ordered by the doctor, it was fully covered. You say that you wanted to return the brace. The Plan denied your request. The Plan says the coinsurance 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 20% of the Medicare-allowable amount for each Medicare-covered item. You have been asked to pay $105.36, which is 20% of the allowed amount for the knee brace. The allowed amount is $526.80 (20% x $526.80 = $105.36). The knee brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. The records show that you received the brace. 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 the knee brace provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe benralizumab injection and therapeuticinjection provided on December 2, 2019.You asked the Plan to waive the cost share forthe benralizumab injection and therapeutic injection. You say that you were informed there wouldbe no cost for the injections.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drugand a$295 copaymentfor Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges andphysician or surgical charges. The benralizumab injection falls within the "Medicare Part B Prescription Drugs" benefit category. The therapeutic injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital OutpatientFacilities 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 cost share forthe benralizumab injection and therapeutic injection provided on December 2, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel One (J7326).You asked the Plan to pre-approve Gel One. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy requirements have not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Gel One. Our reviewer says that the criteria for coverage of Gel One has not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc first before they will approve the requested drug. The provided medical records do not indicate that the patient has tried and failed the required drugs or that the required drugs would likely be less effective or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel One have not been met.Therefore, we decided that the Plan does not have to pre-approve Gel One (J7326).