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

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is currently at the appropriate level of care at, and will continue to cover the current hospital stay at this time.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for multifactorial respiratory failure. She has been treated for COPD and CHF in the setting of morbid obesity. The enrollee is not intubated/ventilated. 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.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating provider without prior authorization.Medicare rulessay 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 4, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesurgical tooth extractions, alveoloplasty, and upper and lower immediate dentures.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the 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. The Plan covers one surgical extraction per calendar year. The services at issue are surgical tooth extractions, alveoloplasty, and upper and lower immediate dentures. Your supplemental benefit with the Plan allows one extraction per calendar year. The Plan approved one extraction on February 15, 2020. Further extractions are not covered by Medicare or your supplemental benefit because they are not being performed to prepare the jaw for radiation treatment. The Plan contract does not list alveoloplasty or immediate dentures as covered benefits and these benefits are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approvesurgical tooth extractions, alveoloplasty, and upper and lower immediate dentures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by an out-of-network provider, on October 17, 2019 to October 19, 2019.
You asked the Plan to waive the coinsurance for injections. You say that you called and made sure that your surgery would be covered. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% coinsurance for Medicare Part B prescription drugs/out-of-network. You have been asked to pay a 50% coinsurance of the allowed amount for injections. The total allowed amount is $4,422.30. The total amount you are being asked to pay is $2,211.16 ($3,322.30 x 50% = $2,211.16). The correct coinsurance has been applied to the injections that were provided. Injections fall within the Medicare Part B prescription drugs/out-of-network 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 coinsurance for injections provided by an out-of-network provider, on October 17, 2019 to October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay for inpatient orthopedic services provided to the enrollee on December 23, 2018.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe denied codes remain not supported.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 the denied codes is:CPT 27130:arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft;CPT 27334:knee arthrotomy with anterior or posterior synovectomy 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is no evidence that the enrollee underwent any procedure on his hip on 12/23/2018. Therefore, the billing of CPT 27130.78 for that DOS is not supported. With CPT 27130.78 having not been supported, the billing of any other procedure withthe 59 modifier is not supported. Therefore, the billing of CPT 27334.78.59 is not supportedWe 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 Plandoes not haveto pay forinpatient orthopedic services provided to the enrollee on December 23, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopic guidance for a spinal injection (77003) provided on September 11, 2019.You asked the Plan to pay for the fluoroscopic guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 77003 is a type I add-on code that was not billed with an acceptable primary procedure code eligible for payment.The Plan must follow Medicare rules. Medicare rules say that an add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner.In this case, the CPT Code Manual definition of code 77003 is fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure). We find that CPT code 77003 is not supported in the record. Specifically, CPT code 77003 is a Type I add-on code and has not been billed with the appropriate primary procedure code. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopic guidance for a spinal injection (77003) provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network BRCA testing for the enrollee.
You asked the Plan to pre-approve out of network genetic testing. You say that The Plan denied your request. The Plan says the requested provider is not 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 out of network BRCA testing for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve19 additional physical therapy visits.You asked the Plan to pre-approve19 additional physical therapy visits. You say that you need your right hand to work. You say that this is not possible in six to nine sessions.The Plan denied your request. The Plan says you reached the maximum benefit from the care you have been receiving.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 19 additional physical therapy visits. 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 that there is no indication of progressive improvement toward treatment goals.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 19 additional physical therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve19 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dupixent injection.You asked the Plan to pre-approve the Dupixent injection. You say that you would like reconsideration as this drug is medically necessary for the treatment ofthe member's condition. The Plan denied your request. The Plan says this medication does not fall under the member's Medicare Part B coverage.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 a Dupixent injection. Benefits for the Dupixent injection may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forautomatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT Code K0606) provided on August 3, 2019 by an in-network provider.You asked the Plan to waive the copayment forthe durable medical equipment (DME). You say that you already paid $3,700 in out-of-pocket costs and regardless of the date of service you feel you have already met your maximum out-of-pocket.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). At the time of service your $3,700 annual out-of-pocket maximum had not yet been met. The claim in question applied $365.30 as your coinsurance which was the remaining responsibility to meet the maximum out-of-pocket $3,700. After the annual in-network out-of-pocket maximum was met all remaining claims processed correctly with no member cost-share. This means that you have been asked to pay the correct amount based onyour 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 forautomatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT Code K0606) provided on August 3, 2019 by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Nuclear Stress Test (78452) provided September 17, 2019
You asked the Plan to waive the copayment for the stress test. You say that the documentation received from the plan shows that the service was $9.5 million dollars and this was calculated incorrectly. The wrong copayment was applied. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Nuclear Medicine Services. You have been asked to pay a $325 copayment for the stress test. The stress test falls within the Nuclear Medicine 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 a Nuclear Stress Test (78452) provided September 17, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.You asked the Plan to pre-approvecontinued inpatient mental health care. You say that that this is medically necessary.The Plan denied your request. The Plan says the enrollee is not expected to improve at this level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our reviewer says that continued inpatient care is not medically necessary at this time. Our physician reviewer found that based on the records provided, it is not expected this enrollee will improve in a reasonable period of time as she does not have suicidal or homicidal ideation noted and denies any auditory or visual hallucinations. The patient has been compliant with treatment while not showing any aggressive or agitated behaviors. It does not appear medically necessary and reasonable to continue psychiatric care at the acute inpatient level of care rather than a lower level of care.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 inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient mental health care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 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, dialysis while temporarily out of the plan's service area 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 services at issue. 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 October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esbriet for enrollee. You asked the Plan to pre-approve Esbriet. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Esbriet for enrollee.Benefits for Esbriet may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from August 20, 2019 through August 23, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on August 20, 2019 and discharged on August 23, 2019. You were asked to pay a $265 copayment per day from August 20, 2019 through August 22, 2019, days 1-3 of your inpatient hospital care. You were discharged on August 23, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $265 copayment per day required for days 1-8. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care from August 20, 2019 through August 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a tissue transfer procedure (14061) provided on October 14, 2019.
You asked the Plan to pay for surgical assistant services. You say that this should be reprocessed and paid. The Plan denied your request. The Plan says surgical assistant services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 14061. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a tissue transfer procedure (14061) provided on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 13, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plandoes not have to pay forthe laboratory services provided on March 13, 2019