Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on December
27, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were not happy with the
services you received. You say that you shouldn't have to pay the copayment. The Plan denied your request.
The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65
copayment for Medicare-covered urgently needed care services.
You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" benefit category. The records show that you were treated during the urgent care
visit. 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 urgent care visit provided on December 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on July 2, 2019.You asked the Plan to waive the copay forthe ambulance transport. You say that this should be covered because it was an emergency.The Plan denied your request. The Plan says that your claim processedand paid correctly by applying the your copayment 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 $260 copay for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $260 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip via ground ambulance 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 copay forthe ambulance transport provided on July 2, 2019.
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 she needs intense physical therapy and is not receiving the level of therapy she currently needs.The Plan denied your request. The Plan says IRF care is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation (PMR) physician. There is no evidence of a need for acute rehabilitation nursing care. The enrollee needs assistance with mobility and activities of daily living. The enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. The complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee cannot tolerate therapies in an IRF. The enrollee's rehabilitation needs can be met at a lower intensity setting such as a skilled nursing facility. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2019by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.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 forthe medical services provided on November 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided by provider on October 24, 2019.You asked the Plan to pay for genetic test. You say that the treating physician ordered this test because it was medically necessary.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not considered medically necessary and is not covered.The Plan must follow Medicare rules. Medicare rules say that procedure code 0005U is not covered by Medicare for date of service October 24, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met.Therefore, we decided that the Plan does not have to pay for oncology (prostate) gene expression profile testing provided by provider on October 24, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term custodial care for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment at a SNF level. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. The enrollee does not have skilled nursing or skilled therapy needs and Medicare does not cover custodial care in a SNF.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term custodial care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for shipping costs and sales tax for services provided by provider on July 16, 2019 and September 11, 2019.You asked the Plan to reimburse you for shipping costs and sales tax. You say that you were told you would receive reimbursement for shipping costs and sales tax related to returning supplies to the supplier.The Plan denied your request. The Plan says there is no benefit for shipping costs or sales tax reimbursement.The Plan must follow Medicare rules. Medicare rules say that Medicare does not separately reimburse shipping cost or sales tax.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shipping costs and sales tax have not been met.Therefore, we decided that the Plan does not have to reimburse you for shipping costs and sales tax for services provided by provider on July 16, 2019 and September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mattress.
You asked the Plan to pre-approve a mattress. You say that The Plan denied your request. The Plan says that your request is not medically necessary because your records show this mattress is not part of a medical bed.
The Plan must follow Medicare rules. The rules say a mattress is covered only where hospital bed is medically necessary. In this case you do not have a hospital bed. Therefore, we decided that the Plan does not have to pre-approve a mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's 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 physician's services provided on September 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight further physical therapy (PT) visits for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee has had a decline in function. The Plan denied your request. The Plan says the services 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 these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has had 20 prior therapy visits and the records do not reveal evidence of significant objective functional improvement from this therapy. The records do not support that she requires 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. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve eight further physical therapy (PT) visits for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee has no acute symptoms that require 24-hour care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued services beyond February 18, 2020, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected to improve your condition, or for the purpose of diagnosis. You were treated under an individualized treatment plan, and were supervised and evaluated by a physician. Treatment beyond February 18, 2020, could be treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions. You were not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services to be provided by
an out of network (OON) provider.
You asked the Plan to pre-approve the outpatient mental health services. You say that the services are
medically necessary. The Plan denied your request. The Plan says there are in-network providers available that
can provide the services at issue.
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 Plan does not have to pre-approve
the outpatient mental health services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora specialist visit and an X-ray provided on October 14, 2019.You asked the Plan to waive the copayments fora specialist visit and an X-ray. You say that you disagree with the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for services obtained by a specialist. Your contract with the Plan also clearly says that you must pay a $14 copayment for X-rays. You received a specialist visit on October 14, 2019. Therefore, you are responsible to pay the $45 copayment. You had an X-ray provided on October 14, 2019. Therefore, you are responsible to pay the $14 copayment. The total amount you owe is: $59. You have been asked to pay the total copayment amount of $59 for a specialist visit and an X-ray. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreedto pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments fora specialist visit and an X-ray provided on October 14, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy (PT) provider.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 Plan does not have to pre-approve a referral to an out-of-network physical therapy (PT) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.You asked the Plan to pre-approve a power mobility device. You say that you want a power mobility device because you cannot walk safely and want to regain your independence.The Plan denied your request. The Plan says you have declined to schedule a PMD evaluation.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD being requested. The case file did not contain a home evaluation, standard written order, or physician face-to-face documentation. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation (76519 LT) provided on October 31, 2019.
You asked the Plan to pay for the ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation. You say that the service was 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 76519 LT is ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation. 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 ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation. Our reviewer says that the service is not supported by the medical records. Our coding reviewer found the medical records provided do not include documentation of a Left Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation, therefore this services cannot be validated as being performed on October 31, 2019. 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 ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation have not been met. Therefore, we decided that the Plan does not have to pay for an ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation (76519 LT) provided on October 31, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay foran electrocardiogram billed with CPT code 93010 for date of service January 10, 2020.You asked the Plan to pay fortheelectrocardiogram. You say that payment for CPT code 93010 performed cannot be included n payment for CPT code 99152 which was performed because these providers have separate specialties. You say that these services are considered separate and should be paid as such.The Plan denied your request. The Plan says that procedure code 93010 is a column II code to the column I code 99152 which was paid out on claim 820200170273522.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to usinformation regarding their decision to deny your request. Specifically, the rule the Plan has cited as the reason for denial states that if a provider reports two codes of an edit pair, only the Column 1 code is payable. However, in this case the electrocardiogram in dispute was billed and the Column 1 code for sedation services was billed. The rule the plan used does not apply to services supplied by different providers, but rather by a single provider. The plan has not substantiated their denial reason.Therefore, we decided that the Plan has to pay foran electrocardiogram billed with CPT code 93010 for date of service January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on October 29, 2019.