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

We decided that the Plan does not have to waive the copayments for an observation stay, the CT scan, and the nuclear medicine study provided from November 19, 2019 to November 20, 2019.
You asked the Plan to waive the copayments for the observation stay, the CT scan, and the nuclear medicine study. You say that you should not be charged for the CT scan or the nuclear medicine study. You say you were not told you were being admitted into observation. 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 $210 copayment for each Medicare-covered outpatient hospital observation stay at a hospital facility and a $200 copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear scans and PET scans, per date of service. You have been asked to pay a total of $591.93 for the observation stay, the CT scan, and the nuclear medicine study. The observation stay falls within the "Outpatient hospital services" benefit category. The CT scan and the nuclear medicine study fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you were admitted to observation and received the diagnostic radiology services while in observation. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
November 19, 2019 to November 20, 2019
Observation
$2,201.70
$210.00
$210.00
November 19, 2019 to November 20, 2019
CT scan
$181.93
$200.00
$181.93
November 19, 2019 to November 20, 2019
Nuclear medicine study
$578.38
$200.00
$200.00
Total
$591.93
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the observation stay, the CT scan, and the nuclear medicine study provided from November 19, 2019 to November 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to approve11 further physical therapy (PT) visits.You asked the Plan to approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says seven visits are approved and 11 further are not medically necessary.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 approve these services. 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 the enrollee is post total knee replacement for arthritis. Seven PT visits have been approved to finalize a home exercise program (HEP) and educate and reinforce the importance of adherence to the HEP. The requested therapy is generally not accepted as specific and effective therapy for the patient's condition. The patient has sufficient authorized therapy to reach a functional level that no longer requires the ongoing skills of a professional therapist. The enrollee has been given extensive instruction in a home exercise program. Services do not only need to be safely and effectively performed by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. 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 approve11 further physical therapy (PT) visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 14,
2020.
You asked the Plan to waive the copayment for the CT scan. You say that you wouldn't know what the
difference in cost would be. You say that the copayment should be $45. 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 $180
copayment for advanced imaging services at an in-network PCP's office, specialist's office and freestanding
radiological facility.
You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The CT scan is considered an advanced
imaging service. 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 CT scan provided on
September 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room services provided March 6, 2020.
You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $120 copayment for Emergency Care. You have been asked to pay a $120 copayment for the Emergency Room services. The Emergency Room services falls within the Emergency Care 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 Emergency Room services provided March 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, you are mostly maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit and/or participate in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for behavioral health services provided from September 10, 2019 to November 1, 2019.
You asked the Plan to hold you harmless for behavioral health services. You say that you believe that Medicare covered the services you received. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because these services are not a covered benefit for the diagnosis codes listed.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. These services were provided by an in-network provider. The file does not show that the Plan provided notice that behavioral health services would not be covered. Under Medicare rules, this means behavioral health services is considered approved by the Plan. No medical records were submitted to support the diagnosis codes billed on these claims. The Plan should ensure that you are not held liable for the denied amounts of these claims. Therefore, we decided that the Plan has to hold you harmless for behavioral health services provided from September 10, 2019 to November 1, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services needed in other settings. 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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies; however, your functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 11, 2019 by a non-contracted 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-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. Wefound 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 December 11, 2019 by a non-contracted provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an acute inpatient rehabilitation facility admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies; however, your functional level does not require or indicate that this therapy must be provided in an inpatient rehabilitation facility with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 3D photographic image provided on January 24, 2020.
You asked the Plan to pay for the 3D photographic image. You say that your gums are receding, and these images were needed to know what is going on and how the dentist could provide treatment. The Plan denied your request. The Plan says this service is not a covered benefit.
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 3D photographic image provided on January 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on November 19, 2019.You asked the Plan to pay for lab test. You say that you are appealing.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because based on the Plan's internal policy this test is not covered when reported with the diagnosis code billed.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this service would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this lab testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on November 19, 2019.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for measles, mumps, and rubella (MMR) vaccine and administration provided on February 24, 2020.
You asked the Plan to pay for immunization. You say that you are planning to travel, so this vaccination was required. The Plan denied your request. The Plan says the denial of payment for these immunization services is correct, because this immunization is not covered by Medicare Part B. The Plan also says that this immunization has been approved under your Medicare Part D benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to immunization. Therefore, we decided that the Plan does not have to pay for measles, mumps, and rubella (MMR) vaccine and administration provided on February 24, 2020.
Benefits for immunization 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a aminophyllin injection (J0280) provided on October 12, 2019.You asked the Plan to pay for the aminophyllin injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed.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 J0280is injection, aminophyllin, up to 250 mg.We find that CPT code J0280is not supported in the record. Specifically, the record indicates that 3 units of 25mg aminophyllin was administered. It is inappropriate to bill3 units as CPT code J0280 suggests up to 250mg.  Based on this information, we decided that Medicare rules for coverage of the aminophyllin injection have not been met.Therefore, we decided that the Plan does not have to pay fora aminophyllin injection (J0280) provided on October 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram provided by a participating provider on February 10, 2020.You asked the Planto waive the copayment for a diagnostic mammogram. You say that this should be billed as a wellness mammogram. The Plan denied your request. The Plan says the correct copayment 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 $130 copayment for outpatient diagnostic tests/outpatient x-rays/other location. You have been asked to pay a $130 copayment for a diagnostic mammogram. Since the mammogram that was provided was diagnostic in nature, the correct copayment has been applied. A diagnostic mammogram falls within the outpatient diagnostic tests/outpatient x-rays/other location 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 diagnostic mammogram provided by a participating provider on February 10, 2020.
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 the service 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 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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services (CPT 99349) provided to the enrollee on August 19, 2019. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the documentation indicates the services are not necessary for treatment of the enrollee's condition. 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 99349 is "Home visit for the evaluation and management of an established patient." We asked our coding 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 was not coded correctly. Our coding reviewer found the documentation submitted was reviewed. This code is a physician-reporting code. The documentation shows that it was an LPN visit. We looked at this coder'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 Plan does not have to pay for home health care services (CPT 99349) provided to the enrollee on August 19, 2019.