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

We decided that the Plan does not have to waive the copayment fora skin graft provided on January 15, 2020.You asked the Plan to waive the copayment fora skin graft. You say that you feel like the enrollee should not be charged a copayment for an outpatient procedure because you could have left him in the hospital which would have resulted in higher charges for the plan.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. The enrollee has been asked to pay a $150 copayment for a skin graft. A skin graft falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora skin graft provided on January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of the wrist (73110) provided on January 31, 2020
by the provider.
You asked the Plan to pay for the x-ray of the wrist. You say that you should not be responsible for the charges.
The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $35
copayment for x-rays provided in a specialist's office.
You have been asked to pay $34.12 (the allowed amount) for the x-ray of the wrist. 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 pay for the x-ray of the wrist (73110) provided on January 31, 2020 by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy (90837) rendered by the out of network
(OON) provider on February 10, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was provided by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not
have to pay for the psychotherapy (90837) rendered by the out of network (OON) provider on
February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemolecular pathology procedures for the enrollee.You asked the Planto pre-approvethe testing. You say that this is medically necessary.The Plandenied your request. The Plansaysthe records must show that the results of the genetic testing would change the enrollee's medical care.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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a chronic cough. A sweat chloride test was abnormal, but not clearly diagnostic of cystic fibrosis. The enrollee's children are asymptomatic. Various genetic tests have been ordered/conducted to determine if the enrollee has cystic fibrosis. While such testing may clarify the diagnosis, they will not affect treatment. Treatment for cystic fibrosis is symptomatic and not curative or genetic. The documentation does not support that the requested/provided testing is/was medically necessary or reasonable.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 Plandoes not haveto pre-approvemolecular pathology procedures for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and pelvis (74177) and emergency room (ER) visit (99284) provided on December 9, 2019 by the provider. You asked the Plan to pay for the CT scan of the abdomen and pelvis and ER visit. You say you should not be responsible for the charges. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $225 copayment for advanced imaging services. You have been asked to pay $225 for the CT scan of the abdomen and pelvis. A CT scan of the abdomen and pelvis 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 pay for the computed tomography (CT) scan of the abdomen and pelvis (74177) and emergency room (ER) visit (99284) provided on December 9, 2019 by the provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current needs cannot be
safely met at a lower level of care. The Plan denied your request. The Plan says that the enrollee does not
require transfer to a LTACH.
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. The patient
is currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. The enrollee was apparently
transiently intubated/ventilated, but is no longer intubated/ventilated. 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. The enrollee can remain at the current
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower
level of care for any ongoing long term care needs. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and topical application of fluoride - excluding varnish provided on February 25, 2020. You asked the Plan to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and topical application of fluoride - excluding varnish. You say that you asked the provider if there was an extra charge for x-rays and the fluoride treatment, and were told no. You also say that you told the provider that you had no extra money for these services. The Plan denied your request. The Plan says these services are not covered. 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. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, additional intraoral periapical x-ray, and topical application of fluoride - excluding varnish provided on February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist x-ray (73110) provided on February 24, 2020 by the provider. 
 
You asked the Plan to pay for the wrist x-ray. You say that you should not be responsible for the follow up xray charges. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $35 copayment for x-rays provided in a specialist's office.  
 
You have been asked to pay $34.21 (the allowed amount) for the wrist x-ray. 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 pay for the wrist x-ray (73110) provided on February 24, 2020 by the provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head or brain
(70450-26-76-77) provided on October 22, 2019 by the appealing provider.
You asked the Plan to pay for the CT scan of the head or brain. You say that the services were provided and
payment should be rendered. The Plan denied your request. The Plan says an inappropriate modifier
combination was used. Therefore, coverage criteria has not been met.
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 70450 is a CT scan of the head or brain.
We find that CPT code 70450-26-76-77 is not supported in the medical record. Specifically, the claim was
billed with an inappropriate modifier code. Based on this information, we decided that Medicare rules for
coverage of the CT scan of the head or brain have not been met. Therefore, we decided that the Plan does not
have to pay for the computed tomography (CT) scan of the head or brain (70450-26-76-77) provided on
October 22, 2019 by the appealing provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve the continued SNF care. You say that you do not expect therapy to return the enrollee to the level of independence he maintained prior to his stay in the hospital. You also say that a longer period of therapy would put the enrollee on track to regain some of his independence and a greater degree of the mobility he enjoyed prior to his hospital stay. The Plan denied your request. The Plan says the physical therapist and occupational therapist documentation indicate good progress and the enrollee is able to continue rehabilitation at lower level of care.
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 continued SNF care. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 continued SNF care have not been met. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve continued SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of the foreman cast provided on December 18, 2019.
You asked the Plan to waive the copayment for the application of the forearm cast. You say that the follow-up care should not be an additional charge for you. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 in-network specialist visit for Medicare-covered services. You have been asked to pay a $35 copayment for the application of the forearm cast. The application of the forearm cast falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the application of the forearm cast is considered a physician service. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.
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 application of a foreman cast provided on December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on February 28, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization 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 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 for pain management services provided on February 28, 2020 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve left atrial appendage closure for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no documentation of a trial and failure of blood-thinning medication for this condition.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 Planwas correct in denying the request to pre-approve the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has atrial fibrillation and no documented medical condition that would increase bleeding risk as well as no medical contraindication that would preclude anticoagulation. A family history of hemorrhagic strokes mentioned does not confer and personal increased risk of hemorrhage on anticoagulation. Therefore, coverage criteria are not met since there is no documentation to indicate the enrollee could not take anticoagulation chronically.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decidedthat Medicare rules for coverage of the procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approveleft atrial appendage closure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on July 17, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records stating exactly which tests were to be performed.The Plan must follow Medicare rules. Medicare rules say that a valid physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay fordrug testing provided on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forabdominal paracentesis with ultrasound provided on January 22, 2020.You asked the Plan to waive the copayment foroutpatient surgery. You say that after performing the ultrasound the provider decided not to perform the surgery.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $350 copayment for outpatient surgery at an outpatient hospital facility. Although the medical records show that the provider made the decision not to perform paracentesis surgery at this visit following the results of ultrasound imaging, the record does show that you were prepared and brought to the procedure room where the surgery was to take place. Therefore, the Planstill makes payment for this procedure at a reduced rate and youroutpatient surgery copayment still applies to this claim.You have been asked to pay $350 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 forabdominal paracentesis with ultrasound provided on January 22, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided October 23, 2019 to October 29, 2019. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee was stable for transport to an in-network facility for inpatient care after initial emergency care. 
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the review indicates that the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a plan facility after the emergency room evaluation. 
 
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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization inpatient hospital care provided October 23, 2019 to October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy.
You asked the Plan to pre-approve Ubrelvy. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says Ubrelvy is not covered under the enrollee's Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy.
Benefits for Ubrelvy may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.