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

We decided that the Plan has to pay for the acute inpatient hospital care provided February 3, 2020, through February 5, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services could have been obtained at an observational level of care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, it was reasonable to believe the enrollee's care would span two midnights. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided February 3, 2020, through February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT genetic testing panel provided on March 18,
2020.
You asked the Plan to pay for the Tempus xT genetic testing panel. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the rendered services were not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that the Tempus xT genetic testing panel is only covered
for certain indications.
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 Tempus xT genetic testing panel. Our
reviewer says that the documentation does not support that the rendered services are medically reasonable or
necessary. Our physician reviewer found the enrollee has metastatic melanoma, stage IV (cT4a, cN2c, cM1a).
A BRAF mutation was not detected on February 8, 2019. Immunotherapy was stopped due to pneumonitis
found in October, 2019. On March 4, 2020 the documented plan was to restart immunotherapy. For Stage IV
enrollees, NCCN Guidelines Version 1.2021 - November 25, 2020 strongly encourages pathologists to test for
the presence of gene mutations (BRAF, KIT) that may impact treatment options for metastatic melanoma. The
clinical value of the Tempus xT genetic testing panel has not been demonstrated. Therefore, the enrollee did
not meet criteria for the services rendered.
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 Tempus xT genetic testing panel have not been met. Therefore, we decided
that the Plan does not have to pay for the Tempus xT genetic testing panel provided on March 18, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee on June 19,
2019.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied
your request. The Plan says a final claim was not received.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the record
does not show that a final claim was submitted for this service. Therefore, we decided that the Plan does not
have to pay for the home health services provided to the enrollee on June 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on February 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 you by an out-of-network provider on February 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 28, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the x-ray is related to procedure 32555.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that a chest radiologic examination CPT code shall not be reported separately from the thoracentesis procedure. We find that CPT code 71045 is not supported in the record. Specifically, the record indicates that this x-ray was following a thoracentesis procedure. It is not appropriate to report this x-ray separately. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on September 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an extremity artery study (93922) provided on August 12, 2020.
You asked the Plan to waive the copayment for an extremity artery study. You say that this should be covered. The Plan denied your request. The Plan says this is covered and processed 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 $160 copayment for each Medicare-covered radiological diagnostic service. You have been asked to pay a $70.12 copayment for an extremity artery study because the allowed amount for this study is less that $160. 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 an extremity artery study (93922) provided on August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the medical equipment provided by an out of network (OON) provider.

You asked the Plan to pay for the walker. You say that you would like reconsideration because you did not receive the necessary equipment before your flight.The Plan denied your request. The Plan says that you received this equipment from an out-of-network provider without 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 record indicates that you were out-of-area on the billed date of service. The record also indicates that the Plan did not have a network provider available to supply you with the necessary equipment in a reasonable time frame.Therefore, we decided that the Plan has to pay for the medical equipment provided by an out of network (OON) provider.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the myocardial perfusion imaging, technetium tc-
99m and regadenoson injection provided on October 1, 2020.
You asked the Plan to waive the cost for the myocardial perfusion imaging, technetium tc-99m and
regadenoson injection. You say that the injections and coinsurance should be covered under the $40 specialist
copayment you already paid. You say that the office is always overcharging, and you refuse to pay the bill. The
Plan denied your request. The Plan says the cost share 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 $175
copayment for each Medicare-covered diagnostic imaging service from an in-network provider and 20%
coinsurance for each Medicare-covered Part B drug from an in-network provider.
You have been asked to pay a total of $222.34 for the myocardial perfusion imaging, technetium tc-99m and
regadenoson injection.
Service Allowed Amount Standard Cost Member Liability
Myocardial Perfusion Imaging
& Technetium TC-99m
$576.82 $175 $175
Regadenoson Injection $236.72 20% $47.34
TOTAL: $222.34
The myocardial perfusion imaging and technetium tc-99m fall within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. The regadenoson injection falls within the "Medicare Part
B prescription drugs" benefit category. Outpatient diagnostic tests and Part B injections are considered separate
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 for the myocardial perfusion imaging, technetium tc-99m and
regadenoson injection provided on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extraction provided on June 16, 2020 by an OON provider.You asked the Plan to pay forthe extraction. You say that you were advised that this treating provider was in-network. You also say that you are on a fixed income.The Plandenied your request. The Plan says this service was rendered by a non-participating provider.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON.Therefore, we decided that the Plan does not have to pay forthe extraction provided on June 16, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe transportation related to kidney services provided between June 11, 2020, and August 24, 2020.You asked the Plan to pay forthe transportation. You say that you should be reimbursed for all ofthe transportation you provided during the enrollee's transplant and dialysis treatment.The Plan denied your request. The Plan says the transportation not directly related to the transplant has been denied.The Plan must follow Medicare rules. Medicare rules say that if an MA plan requires transplant services to be provided at a more distant location, reasonable transportation and lodging costs must be covered.In this case, there is no evidence that the transplant at issue was provided at a more distant location than the normal community patterns of care for kidney transplant services.Therefore, we decided that the Plan does not have to pay forthe transportation related to kidney services provided between June 11, 2020, and August 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care services provided on March 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe subsequent nursing facility care services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided 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 inthis 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 forthe subsequent nursing facility care services provided on March 12, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nine (9) additional physical therapy visits.
You asked the Plan to pre-approve the nine (9) additional physical therapy visits. The Plan denied your request.
The Plan says additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 nine (9)additional physical therapy
visits. Our reviewer says that skilled services are not medically necessary to restore or maintain function or to
prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records
provided there is no documentation that the requested therapy is generally accepted as specific and effective
therapy for your condition. Based on the available records the enrollee appears to have improved with therapy
to the point of being able to manage his activities of daily living. Further formal therapy at this point does not
appear to be necessary to achieve significant improvement in the enrollee's symptoms or functional status.
Further utilization of the home exercise program appears appropriate at this point. Based on the medical
records provided there is no documentation that the unique skills of a professional therapist are required to
safely and effectively provide treatment, that the services can be safely and effectively performed only by a
therapist or under the supervision of a therapist. Based on the medical records provided there is no
documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
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 nine (9) additional physical therapy visits have not been met. Therefore, we
decided that the Plan does not have to pre-approve nine (9) additional physical therapy visits
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology services provided, billed with code 88305-TC-59.

You asked the Plan to pay for the pathology services as billed. You say that this was correctly for two specimens.The Plan denied your request. The Plan says that payment was already made for the global service for code 88305, which includes the technical component. Therefore, no separate payment can be made for the technical component billed with modifier -59.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  

The medical records provided show that the service billed with the-59 modifier is a distinct procedural service. Specifically, it is clearly documented that there were two samples, and that one sample was sent to an outside pathology for interpretation. This supports the use of both modifier -59 and modifier -TC. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.Therefore, we decided that the Plan has to pay for the pathology services provided, billed with code 88305-TC-59.

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 waive the cost-share for the chiropractic services provided from January 8, 2020, through September 9, 2020, by an out-of-network provider.
You asked the Plan to waive the cost-share for the chiropractic services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 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 the chiropractic services from January 8, 2020, by an out-of-network provider. At the time of services rendered you had not met your $500 deductible; therefore, the claims have been processed to apply to your deductible. However, any non-covered chiropractor services are your responsibility. Your EOC states the deductible is $500 and once the deductible has been met you must pay 30% coinsurance for out-of-network Medicare-covered chiropractic services. The only chiropractor services that are covered are manual manipulation of the spine to correct subluxation. 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 for the chiropractic services provided from January 8, 2020, through September 9, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional periapical image (D0230) received on August 10, 2020.
You asked the Plan to pay for the additional x-ray. You say that this should be paid for. The Plan denied your request. The Plan says the benefit only includes coverage for one periapical x-ray per year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit, as one periapical x-ray was already approved by the plan. Only one of these services can be provided in a year. Therefore, we decided that the Plan does not have to pay for an additional periapical image (D0230) received on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on March 19, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 forthe medical services provided to the enrollee by an out-of-network provider on March 19, 2020.