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

We decided that the Plan does not have to pay for the histocompatibility testing you received on January 13, 2020.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this was not medically necessary.The Plan follows Medicare rules. Medicare rules say that histocompatibility testing is covered for the above 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 testing. Our reviewer says that the requested testing was not medically reasonable and necessary. Our physician reviewer found that based on the medical records provided, the enrollee does not meet any of the above indications (A-D) for coverage of the histocompatibility (HLA B27 antigen) testing provided on January 13, 2020. The provider indicated no specific diagnosis or suspicion of ankylosing spondylitis in the available records.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 testing have not been met.Therefore, we decided that the Plan does not have to pay for the histocompatibility testing you received on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for specialist services provided on October 14, 2019.
You asked the Plan to waive the deductible for specialist services. You say that you disagree with the out-of-network charges. 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 $1,500 deductible for out-of-network physician/practitioner services, including doctor's office visits. You received specialist services from an out-of-network provider on October 14, 2019. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had paid $0 toward the $1,500 deductible. Therefore, you are responsible to pay the allowed amount of $1,032.28. 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 $1,500 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time specialist services was received on October 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for specialist services provided on October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 44121) provided on November 18, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service cannot be verified.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 44121 is "Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure)".We asked our coding 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 services. Our reviewer says that the use of CPT code 44121 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation of an "Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure)" being performed on November 18, 2019. The required description is not documented in the operative note of the medical record, therefore this service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the services (CPT 44121) provided on November 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Interspinous and/or interlaminar device.
You asked the Plan to pre-approve Interspinous and/or interlaminar device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has right sided lower back pain radiating to the legs secondary to lumbar spinal stenosis. The requested services remain experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does not meet criteria for the requested 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 Interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve Interspinous and/or interlaminar device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 additional day therapy visits.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you no longer require comprehensive services.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 requested services. Our physician reviewer found that you have ongoing visual and spatial deficits following a cerebral infarction. As of May 12, 2020, you have completed 29 visits of physical therapy. You continue to require moderate to maximum assist for basic activities of daily living. Cognitive deficits are present, post-stroke. In this case, there is no indication prior physical therapy has served to provide sustained, significant improvement in pain and/or function. There is no indication residual deficits could not be addressed via a home exercise program. Therefore, this request is deemed not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve10 additional day therapy visits.
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 enrollee requires frequent neuro checks, labs, and physician monitoring.The Plan denied your request. The Plan says the LTACH would add no additional services.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 physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for ongoing complications following a prolonged hospitalization from December 2019, to April 2020. The enrollee has a tracheotomy and is on a ventilator. The enrollee is receiving daily tracheotomy collar trials. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced leg pump device for the enrollee.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says there is no evidence of a 4 week trial and failure of the basic lymphedema pump.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal physical exam findings of lymphedema of the chest, trunk, or abdomen or unique characteristics that would indicate the segmented pump over a standard pump. The documentation does not reveal a sufficient 4 week trial and failure of the standard pump. The criteria for this request has not been met.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approve an advanced leg pump device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045-26) provided on December 15, 2019 by
the appealing provider.
You asked the Plan to pay for the chest x-ray. You say that the services were provided and payment should be
rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was
processed correctly.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare
coverage criteria have been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the chest x-ray have not been met. Specifically, medical records showing a second chest x-ray was
performed on the date of service in question was not provided. The services are not able to be corroborated
without this documentation. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045-
26) provided on December 15, 2019 by the appealing provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP device (E0601) provided on December 27, 2019.You asked the Plan to waive the coinsurance for the CPAP device. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you rented a CPAP device on December 27, 2019. According to your EOC, enrollees must pay a $15 copayment for Medicare-covered DME and related supplies. Furthermore, in Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of the plan, however, you usually will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of your plan. Under certain limited circumstances the plan will transfer ownership of the DME item. You are asked to pay a $15 copayment for the CPAP device. 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 CPAP device (E0601) provided on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve purchase of a portable oxygen concentrator.
You asked the Plan to pre-approve portable oxygen concentrator.. You say that you need this item because your lungs are only using 50% of their capacity and you have multiple conditions. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because Medicare does not cover the purchase of this item.
The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is not covered by Medicare. Medicare only covers the rental of oxygen equipment. We looked at the file and Medicare rules. This request is for the purchase of a portable oxygen equipment, which is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator. have not been met. Therefore, we decided that the Plan does not have to pre-approve purchase of a portable oxygen concentrator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the thorax (71250) provided January 16, 2020.You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived because you did not need the CT scan. It was the result of a misread X-ray.The Plan denied your request. The Plan says the correct copayment was 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 a $180 copayment for Advanced Imaging Services. You have been asked to pay a $135.32 copayment for the CT scan. The allowable Medicare amount is less than the amount stipulated in the plan contract. The CT scan falls within the Advanced Imaging 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 Computed Tomography (CT) of the thorax (71250) provided January 16, 2020.
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 are appealing. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 has been weaned off of the ventilator to a tracheotomy collar. The enrollee is receiving tube feeds and rehabilitative services. The enrollee can be transferred/discharged to a lower level of care for any ongoing sub-acute or long-term care needs. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6542,
A6543.
You asked the Plan to pre-approve the compression stockings. You say that you require the compression
stockings to treat your lymphedema. The Plan denied your request. The Plan says the compression stockings
are examples of wound care items which are non-covered under the surgical dressing benefit because
they do not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6542,
A6543 are noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6542, A6543.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from January 3, 2020 through January 5, 2020 provided by an in-network provider.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing for reconsideration of the denied charges due to the quality of care that you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits and launched a grievance to address your dissatisfaction with the quality of care you received.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 inpatient hospital care from January 3, 2020 through January 5, 2020 provided by an in-network provider. At the time of services rendered you had not met your $1,000 deductible; therefore, you have been asked to pay $633.85 for the services to apply to your deductible. You then met your deductible and are asked to pay a $725 copayment for the inpatient hospital care. Your EOC states, after you pay your $1,000 deductible, you pay: $725 per in-network inpatient hospital 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 forinpatient hospital care from January 3, 2020 through January 5, 2020 provided by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided January 25, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was appropriate. The Plan denied your request. The Plan says the services were not medically necessary.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found care in a Skilled Nursing Facility is appropriate. The provided records do not support that inpatient level care was needed. 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 not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided January 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses provided on January 15, 2020.You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there must be information in the enrollee's medical record that supports the medical necessity for the item.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. No medical records were received to support the diagnosis on the submitted order, therefore the billed codes cannot be supported. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthoses (L1971) have not been met.Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses provided on January 15, 2020.
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 prior to the date of service you had surgery for a hernia repair. Your daughter brought you dinner and after eating, you began to feel light headed and passed out for a few seconds. You say that your daughter called 911 and the responders came and checked your vitals. You stated that you were feeling fine and told the paramedics that you did not want to go to the hospital. You say that you never went anywhere with the EMS and you feel like the Plan should cover the cost since your daughter did not know if your symptoms were related to your heart or something from your prior surgery. 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 16, 2019. 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.