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

We decided that the Plan does not have to pre-approve acute inpatient admission for an elective knee
replacement surgery.

You asked the Plan to pre-approve the inpatient admission. You say that it is felt this should be approved as
requested. The Plan denied your request. The Plan says the knee replacement has been approved for the
outpatient setting. If the need for a prolonged stay arises after surgery, inpatient admission can be considered at
that time.

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 pre-approve the inpatient admission. Our reviewer
says that the documentation does not support that the criteria for inpatient admission are met in this case. Our
physician reviewer found the enrollee has left knee pain due to arthritis. The enrollee is medically stable, and
the planned procedure is not on the inpatient-only list. The procedure is currently approved as an outpatient
procedure. There is no documentation provided to support the expectation the enrollee will require a greater
than 2 midnight stay.

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 inpatient admission have not been met. Therefore, we decided that the Plan
does not have to pre-approve acute inpatient admission for an elective knee replacement surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery services provided by an out-of-network provider.

You asked the Plan to pay for outpatient surgery services. You say that the services provided were medically necessary and equal with treatment standards. You say that you disagree with the decision to deny this claim. The Plan denied your request. The Plan says authorization for outpatient surgery was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient surgery services provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasonic guidance for a needle placement (76942) provided July 15, 2020.
You asked the Plan to pay for the procedure. You say that the service was medically necessary. The Plan denied your request. The Plan says a required modifier was not included in the claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 76942 is not supported in the medical record. Specifically, per the 2020 Physician Fee Schedule, this CPT code has a Professional Component / Technical Component indicator of 1. The claim has a place of service of 21 (inpatient hospital). In this case, the professional component must be separately billed by the rendering physician with Modifier 26. Modifier 26 was not included with the claim. In this case, the professional component was performed at a location other than where the technical component was performed. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pay for ultrasonic guidance for a needle placement (76942) provided July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on October 8, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says this provider is not a network provider 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided on December 14, 2018 by an out of network (OON) provider.
You asked the Plan to pay for the inpatient care. You say that you had prior authorization for these services. The Plan denied your request. The Plan says the prior authorization was for an observation level of care, not inpatient. Inpatient services were not pre-approved.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the inpatient services provided on December 14, 2018 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the Duplex scan of extracranial arteries; complete bilateral study (93880), Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study (93926) and Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided June 26, 2020.
You asked the Plan to waive the copayments for the Duplex scans (ultrasounds) of your arteries. You say that you were charged less for the same services in 2019 and believe you were billed incorrectly for the services at issue. 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including X-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a total of $331.38 in copayments for the Duplex scans (ultrasounds) of your arteries. This service 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 agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the Duplex scan of extracranial arteries; complete bilateral study (93880), Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study (93926) and Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries (93922) provided June 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan of the head or brain provided on August 15, 2020.
You asked the Plan to pay for the CT scan. You say that the enrollee's Hospice election was revoked on August 12, 2020, when the enrollee was admitted as an inpatient. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 12, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the CT scan of the head or brain provided on August 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an X-ray provided on November 30, 2020.
You asked the Plan to waive the copayment for an X-ray. You say that you thought that X-rays were included in the office. 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 $0 copayment for X-rays provided in a primary care physician's office and an $85 copayment when provided by any other provider. The record shows that you received an X-ray at a specialist office on November 30, 220. Therefore, you are responsible to pay the allowed amount of $33.61, which is less than the $85 copayment. You have been asked to pay $33.61, which is less than the $85 copayment for an X-ray. 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 agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an X-ray provided on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four tooth extractions provided on May 12, 2020.
You asked the Plan to pay for the tooth extractions of #'s 11, 12, 13 and 15. You say that you thought the dentist was in-network. The Plan denied your request. The Plan says they will reprocess the claims as a one-time exception to allow coverage for the out of network services.
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, your quarterly maximum allowed was met. Therefore, we decided that the Plan does not have to pay for the four tooth extractions #11, 12, 13 and 15, provided on May 12, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care provided by an out of network provider on November 2, 2020.
You asked the Plan to pay for nursing facility care. You say that the doctor was not responsible to get authorization. You say that the claim should be processed for reimbursement. The Plan denied your request. The Plan says services provided by non-participating 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for nursing facility care provided by an out of network provider on November 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on June 25, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you took a taxi and the charges are fictitious. 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 $260 copayment for ambulance services. The medical records show that you received ambulance services on June 25, 2020. Therefore, you are responsible to pay the $260 copayment. You have been asked to pay a $260 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on June 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 in the Medicare rules section. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the hospital services (inpatient and outpatient) provided from July 14, 2020 to July 17, 2020.
You asked the Plan to waive the cost-share for the hospital services. You say that you were not admitted as an inpatient until July 16, 2020 and you do not understand why you are being billed so much when you did not have your scheduled surgery. The Plan denied your request. The Plan says you received care prior to being admitted as an inpatient. Inpatient care requires 10% coinsurance. You also had not met your annual deductible at the time of the service.
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 10% coinsurance for inpatient hospital care after you meet your annual $300 deductible. You have been asked to pay $697.01 for the hospital services. The bill covers all of your inpatient care, including drugs, therapies, testing, and emergency department services. The record shows that at the time of service, you had $287.29 left to pay before you met your deductible. The Plan's allowed amount for the services provided came to $4,384.53. After your deductible is paid, the Plan will pay their portion of the remaining $4,097.23 ($4,384.53 - $287.29 = $4,097.23). The services fall under the inpatient hospital care benefit category, which means you pay 10% of $4,097.23 ($4,097.23 x 10% = $409.72) as well as your deductible ($287.29 + $409.72 = $697.01).
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 hospital services (inpatient and outpatient) provided from July 14, 2020 to July 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for immunotherapy provided on October 21, 2020.
You asked the Plan to waive the copayment for immunotherapy. You say that you have never had to pay in the past. 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 $35 copayment for specialist services. You have been asked to pay $10, which is less than the $35 copayment for immunotherapy. Immunotherapy 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 copayment for immunotherapy provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463) provided June 26, 2020.
You asked the Plan to waive the copayment for the hospital outpatient clinic visit. You say that you did not know prior to the services what the cost would be and did not expect to receive the bill with the copayment at issue. The Plan denied your request. The Plan says the copayment was 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 $300 copayment for each Medicare-covered Outpatient Hospital Facility visit. You have been asked to pay $110.28 as your copayment for the hospital outpatient clinic visit. This visit falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the hospital outpatient clinic visit (G0463) provided June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99231) provided August 14, 2020.
You asked the Plan to pay for the physician services. You say that these services were medically necessary. The Plan denied your request.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99231 is not supported in the medical record. Specifically, these payment for these physician services was bundled in payment for the anesthesia package billed with CPT code 01360. The post-operative physician services are not eligible for separate payment. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99231) provided August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9502) provided from August 22,
2020, to August 28, 2020.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the CPT code billed is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9502 is not supported in the medical record. Specifically, per the 2020 National
Physician Fee Schedule, this CPT code is marked with a status of "I" which means it is not valid for Medicare
purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services
have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services
(S9502) provided from August 22, 2020, to August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the office visit in question is related to a COVID-19 billing code. The Plan denied your request. The Plan says criteria for meeting out of network coverage has not been met.
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 attempted to obtain medical records for the requested office visit. The non-participating provider's office failed to produce records from the office visit. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit.

You asked the Plan to pay for the chiropractic office visit. You say that without the office visit the provider would not know what treatment is necessary. The Plan denied your request. The Plan says the office visit is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit.