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

We decided that the Plan does not have to pay for physician's services provided on May 16, 2019 and August 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network 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 did not pre-approve the servicesat 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 May 16, 2019 and August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pay for the home health services provided to the enrollee from October 24, 2019.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says requests for a Treatment Authorization Code have been made, and an appeal review cannot be conducted until that code is received.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim has been submitted without the required Treatment Authorization Code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 10, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory test. You say that you do not actually see the enrollee and cannot return the enrollee's sample.The Plandenied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to payfor these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided July 12, 2019 to July 14, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says the medical need for inpatient level of care is not shown.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects thepatient 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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided July 12, 2019 to July 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skin surgery provided on May 13, 2019.You asked the Plan to waive the copayment forthe skin surgery. You say that you submitted your bill for review. You say you do not know what the bill is for. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules saya 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 $275 copayment for each Medicare-covered ambulatorysurgical center visit. You have been asked to pay a $275 copayment for the skin surgery. The skin 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 forthe skin surgery provided on May 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe custodial care provided from May 31, 2019 to June 30, 2019.You asked the Plan to pay forthe custodial care. You say that the services were necessary because you cannot be left alone. You also say that you are on a fixed income and cannot afford these payments on your budget.The Plan denied your request. The Plan says your condition did not require daily skilled services at an inpatient SNF 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 pay for the custodial care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did 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 custodial care have not been met.Therefore, we decided that the Plan does not have to pay forthe custodial care provided from May 31, 2019 to June 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe psychotherapy services (90832) provided on September 11, 2019. You asked the Plan to pay forthe outpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says the out-of-network services were not preauthorized or emergent. There were network providers able to provide the services at issue.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception thatwould require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe psychotherapy services (90832) provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 to October 22, 2019 by anon-contracted provider.You asked the Plan to pay forthese services. You say that the provider told you that they accepted your insurance.The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 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. The Plan cannot be held responsible for possible misinformation given regarding your coverage from a non-contracted provider. 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 September 24,2019 to October 22, 2019 by a non-contracted provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe fecal occult blood testing rendered to you on November 30, 2018.You asked the Plan to pay forthese services. You say that the doctor ordered the tests.The Plan denied your request. The Plan says the testing exceeds the benefit limit.The Plan mustfollow Medicare rules. The rules say that Medicare covers one fecal occult blood test every 12 months.We looked at the file and Medicare rules. The file shows that you previously received a fecal occult blood test in June of 2018. The Plan approved thistest as a one-time exception. The services rendered on the date of service at issue exceeded the Medicare benefit limit.Therefore, we decided that the Plan does not have to pay forthe fecal occult blood testing rendered to you on November 30, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Contour Next Test StripsYou asked the Planto pre-approvethe strips. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical information submitted does not establish medical necessity.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 strips. Our reviewer says that the requested brand is not medically reasonable or necessary. Our physician reviewer found a non-preferred brand of test strips was requested. No rationale for use of this particular brand was submitted. There is not a medical necessity to make an exception and approve a non-preferred brand.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 strips have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Contour Next Test Strips
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on December 3, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on December 3, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided on September 23, 2019.You asked the Plan to pay forthe non-emergent ambulance transport. You say that prior authorization was not required if medically necessary.The Plan denied your request. The Plan says prior authorization is required for non-emergent ambulance services.Medicare pays for ambulance services onlywhen they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The contract says prior authorization rules apply. Based on this information, we decided that Medicare rules for coverage of thenon-emergent ambulance transport have not been met.Therefore, we decided that the Plan does not have to pay forservices provided on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 12, 2019 to the enrolee by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you are not aware of how authorization is obtained.The Plan denied your request. The Plan says the services were rendered 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 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 August 12, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment formyocardial perfusion imaging provided on November 6, 2019.You asked the Plan to waive the copayment formyocardial perfusion imaging. You say that you thought that you would only owe a $40 copayment.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 mammography and ultrasounds and a $200 copayment for all other diagnostic and nuclear medicine radiological services.You received myocardial perfusion imaging on November 6, 2019.Myocardial perfusion imaging is considered nuclear medicine.Therefore, you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 formyocardial perfusion imaging provided on November 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe eye exam, visual field exam and ophthalmic imaging provided on November 4, 2019.You asked the Plan to waive the deductible forthe eye exam, visual field exam and ophthalmic imaging. You say that you were assured your doctor was in-network. You say that these bills should be covered.The Plan denied your request. The Plan says the deductible applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Out-of-network services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for fall within the "Vision care" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit categories. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network vision care and out-of-network diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the eye exam, visual field exam and ophthalmic imaging were received on November 4, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe eye exam, visual field exam and ophthalmic imaging provided on November 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient staywith an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapyprogram. There is concern that the enrollee would not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe podiatry services rendered to the enrollee on August 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 11720 and G0127 are 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 code 11720 is debridement of nail(s) by any method(s); 1 to 5. The definition of code G0127 is trimming of dystrophic nails, any number.We find that CPT codes 11720 and G0127 are not supported in the medical record. Specifically, the documentation contains no records to support that debridement of 1-5 nails and trimming of dystrophic nails was performed on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe podiatry services rendered to the enrollee on August 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forcataract surgeries provided from July 22, 2019 to July 31, 2019.You asked the Plan to waive the copayments forcataract surgeries. You say that you should only owe a $200 copayment per each service.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 $400 copayment for outpatient surgery services.You received cataract surgeries at an outpatient hospital facility on July 22, 2019 and July 31, 2019. Therefore, you are responsible to pay a $400 copayment per each visit. The total amount you owe is: $800.00. You have been asked to pay the total copayment amount of $800.00 for cataract surgeries. Cataract surgeries fallwithin 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 copayments forcataract surgeries provided from July 22, 2019 to July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 25, 2019 to the enrollee by an out of network (OON) provider.You asked the Plan to pay forthese 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 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 providersonly 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 25, 2019 to the enrollee by an out of network (OON) provider.