Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicarerules 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 thecomplexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a bowel obstruction and surgery to treat the obstruction. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs.The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist office visit (99213) and echocardiography (93350) provided May 21, 2019.You asked the Plan to waive the copayments forthe specialist office visit and echocardiography. You say that you should not be charged the copayments.The Plan denied your request. The Plan says the copayments were applied correctly.The rules saya 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 youmust pay a $50 copayment for all other diagnostic procedures and tests. A separate office visit copay applies for diagnostic tests and procedures, diagnostic radiology and therapeutic radiology. The contract also says that enrollees must pay a $45 copayment for each specialist office visit.You have been asked to pay atotal of $95 in copaymentsfor the specialist office visit and echocardiography. The echocardiography falls within the Outpatient diagnostic tests and therapeutic services and supplies and the specialist office visit falls within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe specialist office visit (99213) and echocardiography (93350) provided May 21, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee on July 2, 2020 and July 3, 2020.
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 these services are the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee on July 2, 2020 and July 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DyAnsys electro-acupuncture device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says devices used for electro-acupuncture are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that acupuncture for stimulation of auricular points is not a
covered Medicare benefit.
The requested device is considered an auricular electro-acupuncture device. Based on this information, we
decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan
does not have to pre-approve DyAnsys electro-acupuncture device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 molecular pathology testing provided to the enrollee on November 2, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says Medicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling.
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 various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 molecular pathology testing provided to the enrollee on November 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram monitoring and analysis (93270, 93271) rendered by the out of network (OON) provider on September 3, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the electrocardiogram monitoring and analysis (93270, 93271) rendered by the out of network (OON) provider on September 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on May 11, 2020.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of the testing.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe laboratory services have not been met. Specifically, the record does not include clinical documentation to determine the medical necessity for these services.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on May 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the Cardiac rehabilitation services (93798) provided September 2, 2020 through September 30, 2020.
You asked the Plan to waive the copayments for the Cardiac rehabilitation services. You say that you were told there would be no charge. The Plan denied your request. The Plan says the copayments were 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 $25 copayment for each cardiac rehabilitation service provided in a specialist's office or outpatient hospital. You have been asked to pay a $25 copayment per visit for the cardiac rehabilitation services. The total amount you are being asked to pay is $150 ($25 x 6 visits = $150). Cardiac rehabilitation services fall within the Cardiac 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 Cardiac rehabilitation services (93798) provided September 2, 2020 through September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe photodynamic therapy provided on October 20, 2020.You asked the Plan to waive the cost share forthe services provided. You say that the procedure was done incorrectly the first time.The Plan denied your request. The Plan says the coinsurance applied was correct, and cannot be waived.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 cost for Medicare Part B prescription drugs. You have been asked to pay 20% of the cost for the services provided. The services fallwithin the Medicare Part B prescription drugs benefit category. The cost share is applied based on the services provided, and not by the outcome of previous services. 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 photodynamic therapy provided on October 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for a mastectomy bra at an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a network provider available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral for a mastectomy bra at an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forendoscopy services provided on October 12, 2020.You asked the Plan to waive the copayment forendoscopy services. You say that this had a $250 copay last time you had these services. The Plan denied your request. The Plan says that the copay for outpatient surgery services is $450 in 2020.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 $450 copayment for outpatient surgery. You have been asked to pay a $450 copayment for endoscopy services. The endoscopy services fall within the outpatient surgery 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 forendoscopy services provided on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the charges forthe diphenhydramine provided on July 1, 2020.You asked the Plan to waive the charges forthe diphenhydramine. You say that you should not be charged this $10.35 because you already paid for these services.The Plan denied your request. The Plan says this drug was billed to the plan by the provider, and the 20% coinsurance was correctly applied.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 drugs covered under Medicare Part B. You have been asked to pay20% coinsurance for the diphenhydramine. The diphenhydramine falls within the drugs covered under Medicare Part B 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 charges forthe diphenhydramine provided on July 1, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe post stabilization inpatient care provided to the enrollee from 2:05 PM on July 4, 2020 through July 6, 2020.You asked the Plan to pay forthe post stabilization inpatient care. You say that these services were medically necessary.The Plan denied your request. The Plan says that the enrollee was stable for transfer.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay fornecessary 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 the post stabilization inpatient care. Our reviewer says that post stabilization inpatient care was not medically reasonable and necessary for the enrollee. The patient presented to the emergency departmentwith shortness of breath for one week. He was started on steroids and bronchodilators as well as 2L oxygen. Labs were unremarkable and CXR without acute changes. His symptoms improved while in the emergency department. There was no report of the patient being unstable for transfer. The enrollee appeared to be stable for transfer at 2:05 PM on July 4, 2020 based on the documentation provided. Our physician reviewer found that the enrollee's condition did not meet criteria for post stabilization inpatient 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 the post stabilization inpatient care have not been met.Therefore, we decided that the Plan does not have to pay forthe post stabilization inpatient care provided to the enrollee from 2:05 PM on July 4, 2020 through July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like reconsideration because the LTACH admission is medically necessary.The Plan denied your request. The Plan says the member may receive the necessary care in their current inpatient hospital setting.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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin D laboratory panel provided to the enrollee on March 8, 2019.
You asked the Plan to pay for the panel. You say that this should be paid for. The Plan denied your request. The Plan says Medicare says tests with no relation to a diagnosis for the health of the patient are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The requested vitamin panel is not considered medically reasonable or necessary by Medicare. Based on this information, we decided that Medicare rules for coverage of the panel have not been met. Therefore, we decided that the Plan does not have to pay for a vitamin D laboratory panel provided to the enrollee on March 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 19, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided on June 19, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID testing (U0003 and G2024) provided on August 28, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this service was reported correctly. The Plan denied your request. The Plan says there is no evidence of a relationship with the ordering physician and no laboratory results submitted for the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the record does not include laboratory results for the billed date of service. Additionally, the record submitted does not include documentation of why these services were ordered. Therefore, we decided that the Plan does not have to pay for the COVID testing (U0003 and G2024) provided on August 28, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora psychiatric diagnostic evaluation (90791) provided on September 1, 2020.You asked the Plan to waive the copayment fora psychiatric diagnostic evaluation. You say that you should not have to pay the copayment. The Plan denied your request. The Plan says the copayment was applied correctly.The rules say a plan must discloseto 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 outpatient mental health care. You have been asked to pay a $40 copayment for a psychiatric diagnostic evaluation. A psychiatric diagnostic evaluation falls within the outpatient mental health 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 fora psychiatric diagnostic evaluation (90791) provided on September 1, 2020.Your complaint about the provider potentially not doing anything for you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visits (G0463) rendered by the out of network (OON) provider from August 14, 2020, through September 23, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 hospital outpatient clinic visits (G0463) rendered by the out of network (OON) provider from August 14, 2020, through September 23, 2020.