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

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on December 3, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not provided any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on February 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an x-ray. You say that you cannot afford this. You say that this was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 an x-ray provided on February 5, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says it is not seen that this is an emergency, or that the services requested cannot be provided within a reasonable distance in-network.
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 provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystoscopy provided on March 16,
2020.
You asked the Plan to reduce the copayment for the cystoscopy. You say that you weren't informed the
copayment would be this high. You say that the cystoscopy should be covered with a $30 specialist 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 $350
copayment for an outpatient hospital facility.
You have been asked to pay a $350 copayment for the cystoscopy. The cystoscopy falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. The cystoscopy is considered a surgical procedure that was provided by the hospital. 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 reduce the copayment for the cystoscopy provided on March 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide. You say that you have trouble getting around and performing activities of daily living. The Plan denied your request. The Plan says the denial of authorization for the requested home health aide is correct.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide. Our reviewer says that you do not meet the Medicare criteria for the requested home health aide services. Our physician reviewer found home health aide services are not reasonable and necessary to the treatment of your illness or injury by skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the physical therapy visits provided from May 30, 2019 to July 5, 2019.You asked the Plan to waive the coinsurance for the physical therapy visits. You say that you were approved for the therapy visits. You say if you had known the provider was out-of-network you would have chosen a different provider. 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 10% of the cost for each out-of-network Medicare-covered outpatient rehabilitation service. You have been asked to pay a total of $116.09 for the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows the provider is out-of-network. See chart below. 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 physical therapy visits from May 30, 2019 to July 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three additional physical therapy and speech therapy home health visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says a partial reduction of services through 7/22/20 is needed.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. In-home skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point, as a practical matter, can be provided at a lower level of care (ex. outpatient rehabilitation, HEP). 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve three additional physical therapy and speech therapy home health visits for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a CT scan and an X-ray provided from August 1, 2019 to September 20, 2019.
You asked the Plan to waive the copayments for a CT scan and an X-ray. You say that you feel that the charges should be processed as in-network. 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 $225 copayment for CT scans provided by a provider other than a primary care provider and a $25 copayment for X-rays performed by a provider other than a primary care provider. You received a CT scan on September 11, 2019. Therefore, you are responsible to pay the $225 copayment. You received an X-ray on September 20, 2019. Therefore, you are responsible to pay the $25 copayment. The total amount you owe is: $250. You have been asked to pay the total copayment amount of $250 for a CT scan and an X-ray. A CT scan and an X-ray fall 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 a CT scan and an X-ray provided from August 1, 2019 to September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bio-electro-magnetic-energy-regulation device.
You asked the Plan to pre-approve a bio-electro-magnetic-energy-regulation device. You say that this device helps your blood flow circulation, bowel function, muscle relaxation, stamina, and fatigue. The Plan denied your request. The Plan says there is not enough peer reviewed data on the safety and effectiveness of this device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
We looked at the file and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. This device is not intended to diagnose, treat, cure or prevent any disease. Based on this information, we decided that Medicare rules for coverage of a bio-electro-magnetic-energy-regulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve a bio-electro-magnetic-energy-regulation device.
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 on the date of service the enrollee was experiencing an emergency and you called the Plan provided emergency number. You say that you were advised by the nurse to call 911 and soon after the EMT responders arrived. They administered an IV and evaluated the enrollee. You say that the enrollee refused to go to the hospital in the ambulance and instead chose to follow up with his own physician. You say that the ambulance was not requested. 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 August 22, 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.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for specialist services. We decided that the Plan does not have to reduce the cost-sharing charges for specialist services to the amount you requested. You asked the Plan to reduce the cost-sharing charges for specialist services. You say that you already met the deductible amount and disagree with the charges. The Plan says that the claims were processed correctly and you are being charged the correct amount. We decided that the Plan has to reduce the cost-sharing charges for specialist services from $295.51 to $35. The Plan contract says that there is a $750 deductible. The deductible does not apply to primary care physician or specialists visits (deductible could apply for additional services performed on the same day in the physician's office). The Plan contract also says that enrollees must pay a $35 copayment for each specialist visit. The health plan contract does not specifically list which physician services are excluded from deductible charges. Since physician services were rendered, you cannot be asked to pay more than the $35 copayment for specialist services. Therefore, we decided that the Plan has to reduce the cost-sharing charges for specialist services from $295.51 to $35. We also decided that the Plan does not have to reduce the cost-sharing charges for specialist services to the amount you requested. 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. Therefore, we decided that the Plan does not have to waive the $35 copayment for specialist services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 lab work provided on September 18, 2019 by an out of network (OON) 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.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, your ongoing care needs include respiratory support with tracheostomy care, surveillance laboratory studies, tube feeding, and therapy services. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Therefore, you do not meet criteria for the requested admission. 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: Lab
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an ultrasound of the bladder. We decided that the Plan does not have to reduce the cost-sharing charges for an ultrasound of the bladder to the amount you requested. You asked the Plan to reduce the cost-sharing charges for an ultrasound of the bladder. You say that you disagree with the additional charges because you have never been charged in the past.The Plan says that the claims were processed correctly and you are being charged the correct amount.We decided that the Plan has to reduce the cost-sharing charges for the ultrasound of the bladder from $40 to $10.87. The plan contract says that enrollees must pay 20% coinsurance for diagnostic imaging. Therefore, you cannot be asked to pay more than $10.87 for the ultrasound.Therefore, we decided that the Plan has to reduce the cost-sharing charges foran ultrasound of the bladder from $40 to $10.87. We also decided that the Plan does not have to reduce the cost-sharing charges forthe ultrasound of the bladder to the amount you requested. 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 20% coinsurance for diagnostic imaging. The allowed amount is $54.36 and 20% of that is $10.87.Therefore, we decided that the Plan does not have to waive the coinsurance for an ultrasound of the bladder.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.You asked the Plan to pre-approve Rituxan. You say that the plan is for the enrollee to proceed with treatment under a clinical trial.The Plan denied your request. The Plan says the requested use of the drug is not supported.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve Rituxan as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services provided on February 11, 2020.You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 73560 is radiologic examination, knee; 1 or 2 views.We find that CPT code 73560 is not supported in the medical record. Specifically, the diagnosis code billed with this code, M17.11 (Unilateral primary osteoarthritis, right knee) is mismatched to the anatomical procedure modifier on the claim line (modifier LT). Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met.Therefore, we decided that the Plan does not have to pay forthe x-ray services provided on February 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy service provided form October 22, 2019 to January 21, 2020.
You asked the Plan to pay for the home infusion therapy service (S9328). You say that the Plan should pay this claim. The Plan denied your request. The Plan says S codes are not payable by Medicare.
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 S9328 is Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy service provided form October 22, 2019 to January 21, 2020.