Persius/hicric huggingface dataset:
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 in this case is receiving appropriate care for their needs at this time. The enrollee does not require services at the LTACH that are not already available at the current acute care hospital. There are no services available at the proposed LTACH that the enrollee requires now that are not already available and covered at the current acute care hospital. Therefore, without sufficient support made for this request, the LTACH services will be considered not medically necessary for the enrollee at this time. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 13, 2019. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the payment is denied as the provider is privately contracted. 
 
The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare.    We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on December 16, 2019. You asked the Plan to reduce the copayment for the office visit. You say that you feel you should have been charged a $5 copayment for the office call instead of a $50 specialist copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $5 copayment for each in-network Medicare-covered visit with a primary care physician. The Plan says you must pay a $55 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $5 copayment for the office visit. The records show that an office visit was provided and billed by a primary care physician. The records do not support that you were seen at an urgent care facility. Therefore, we decided that the Plan has to reduce the copayment for the office visit provided on December 16, 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: 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 still medically compromised. The Plan denied your request. The Plan says you cannot tolerate 3 hours of daily intense therapy. 
 
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 physician reviewer found that you were admitted to the acute care hospital with atypical measles syndrome. There were no overnight events or complaints. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from December 4, 2018 to March 19, 2019. You asked the Plan to pay for these services. The Plan denied your request. The Plan says that this service was bill incorrectly. The Plan must follow Medicare rules. The rules say that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. You are billing for home infusion services S9328. This is not a valid code for Medicare purposes and the plan does not offer an additional benefit for this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (S9328) provided to the enrollee from December 4, 2018 to March 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular services. You asked the Plan to pre-approve vascular services. You say that you need services to help with hernia pain. The Plan denied your request. The Plan says there are no records to support medical necessity. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The file shows that studies of extracranial arteries, lower extremity arteries, and a complete vascular study were requested. We looked at the file, and Medicare rules. In this case, there were insufficient medical records to confirm the requested services are medically reasonable and necessary to treat your medical conditions. Based on this information, we decided that Medicare rules for coverage of vascular services have not been met. Therefore, we decided that the Plan does not have to pre-approve vascular services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care provided on February 11, 2020. 
 
You asked the Plan to waive the copayment for the wound care. You say that you disagreed with your bill  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 $225 copayment per visit for outpatient surgery or procedure.  
 
You have been asked to pay a $225 copayment for the wound care. The wound care 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 copayment for the wound care provided on February 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays provided on November 27, 2019. You asked the Plan to pay for the periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays. You say that you were not told that this provider had opted out of Medicare. You also say that the provider's office told you that as of January 21, 2020, this provider would not be in network, and you would have to use out-of-network benefits. The Plan denied your request. The Plan says the treating provider has opted out of Medicare and was opted out on this date of service. 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 periodic oral evaluation, prophylaxis, and complete series of intraoral x-rays provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Monovisc injection provided on December 26, 2019. You asked the Plan to waive the coinsurance for the Monovisc injection. You say that she needed the injection in her knee. You say that the cost for one injection is too high. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B covered drugs from an in-network provider. The enrollee has been asked to pay $4,699.88, which is less than the standard 20% coinsurance for the Monovisc injection because the maximum out-of-pocket was met. The Monovisc injection falls within the "Medicare Part B prescription drugs" 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 for the Monovisc injection provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on September 24, 2019.
You asked the Plan to waive the coinsurance for the office visit. You say that you have been seeing this doctor for the past 20 years. You say you would like the Plan to process this visit as your annual wellness visit with not cost share. 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 30% coinsurance for annual out-of-network annual routine physical. You have been asked to pay $41.51 which is 30% of the allowed amount for the office visit. The allowed amount is $138.38. ($138.38 x 30% = $41.51). The office visit falls within the "Annual routine physical" benefit category. The record shows that the provider is out-of-network.
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 office visit provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 27, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and
approved for payment. You say that you were told that everything was all set. The Plan denied your request.
The Plan says 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 physician services provided on January 27, 2020
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 23, 2019. 
 
You asked the Plan to pay for the pump assembly and operation.. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is included in the DRG payment to the facility. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation. have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for educational supplies provided on December 2, 2019. 
 
You asked the Plan to pay for the provided supplies. The Plan denied your request. The Plan says the code is included in the payment of other services performed on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  
 
In this case, we have confirmed that code 99071 has a bundled relationship and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for educational supplies provided on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on January 8, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services and these services could have been provided in the PCP's office. 
 
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 lab work provided on January 8, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Mohs surgery provided on February 24, 2020. 
 
You asked the Plan to waive the copayment for Mohs surgery. You say that you've had a similar surgery and never had a copayment. The Plan denied your request. The Plan says the $200 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 $200 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.  
 
You have been asked to pay a $200 copayment for Mohs surgery. Mohs surgery 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 Mohs surgery provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the enrollee's care was medically justified to receive the services.The Plan denied your request. The Plan says the services were not urgent, or approved in advance.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 servicesat 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 forthe medical services provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 25, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the Plan benefits. Services rendered by non-participating providers require prior authorization.Medicare rules say that plans can require enrollees to get care fromnetwork 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 servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift.
You asked the Plan to pay for a stair lift. You say that previously you had a bad fall which resulted in severe injuries and hospitalization. You say that when you were discharged from the hospital, you were unable to get up and down the stairs or walk. You stated that the stair lift was necessary to help you move around your home. You say that you can now walk with the assistance of a walker, however the stair lift is still necessary for you to go up and down your stairs. You believe the stair lift should be covered under your Plan benefits. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair lift.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on January 14, 2020.
You asked the Plan to pay for the diagnostic digital breast tomosynthesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77062 has a status code of I which is not valid for Medicare purposes.
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 77062 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 77062 has a status code of I. This means that CPT code 77062 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (77062) provided on January 14, 2020.