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

We decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on January 31, 2019.
You asked the Plan to pay for the hospital discharge day management services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records submitted document that less than 30 minutes of time was spent on discharge services.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records indicate that less than 30 minutes of hospital discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (99239) provided on January 31, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvea breast implant removal surgery.You asked the Plan to pre-approvethe breast implant removal surgery. You say that the implant in your left breast was recently recalled by FDA and Allergan due to a higher occurrence of breast implant-associated anaplasticlarge-cell lymphoma in patients who have Allergan BIOCELL textured implants. You say that you don't want to wait to see if you are one of the patients that will get BIA-ALCL and prefer the preventive measure of replacing the implant while you are healthy.The Plan denied your request. The Plan says that the FDA does not recommend removal of the Allergan implant in asymptomatic patients.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 breast implant removal surgery. Our reviewer says that the breast implantremoval surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the FDA has identified this as a Class I recall, the most serious type of recall. Use of these devices may cause serious injuries or death. Allergan Recalls Natrelle Biocell Textured Breast Implants Due to Risk of BIA-ALCL Cancer. The FDA requested that Allergan recall all BIOCELL textured breast implants and tissue expanders marketed in the U.S. due to risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a cancer of the immune system. Based on the currently available information, the FDA's analysis demonstrated that the risk of BIA-ALCL with Allergan BIOCELL textured implants is approximately 6 times the risk of BIA-ALCL with textured implants from other manufacturers marketing in the U.S. and continued distribution of Allergan's BIOCELL textured breast implants would likely cause serious, adverse health consequences, including death, from BIA-ALCL. Implant exchange with a smooth typed implant should be considered medically necessary in order to prevent a 6 time increase in development of BIA-ALCL, which is a malignancy 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 breast implant removal surgery have been met.Therefore, we decided that the Plan has to pre-approvea breast implant removal surgery.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 pre-approve physician's services to be provided by "the doctor".You asked the Plan to pre-approve the physician's services. You say that you have been under the care of this physician for an extended period of time and he has been treating your existing condition since being a patient. You say that you are not comfortable with switching specialists in the middle of your condition or treatment. The Plan denied your request. The Plan says you 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by "the doctor".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the skin surgery provided on October 16, 2019 to October 25, 2019.
You asked the Plan to reduce the copayment for the skin surgery. You say that you did not have surgery at a hospital. You say you had your surgery at an outpatient surgery center. 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 $250 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay a $250 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. The record shows you were billed by the outpatient 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 skin surgery provided on October 16, 2019 to October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 8, 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-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 for the medical services provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 12, 2019 through September 18, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient 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 September 12, 2019 and discharged on September 18, 2019. You were asked to pay a $290 copayment per day from September 12, 2019 through September 15, 2019, days 1-4 of your inpatient stay. There were no copayment charges from September 16, 2019, day 5 of your inpatient hospital care until your day of discharge September 18, 2019. Per your contract there is a $290 copayment per day required for days 1-4. 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 inpatient hospital care from September 12, 2019 through September 18, 2019 provided by an in-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 11, 2019.
You asked the Plan to pay for the physical therapy 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 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 physical therapy services provided on June 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 16, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the 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 provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 the laboratory services provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Domiciliary or Rest Home Visit with an Established Patient (99335) provided on November 6, 2019 by an out-of-network Physician. You asked the Plan to pay forthe physician services. You say that the claim should be covered.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were in-network physicians that could render 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 items/services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe Domiciliary or Rest Home Visit with an Established Patient (99335) provided on November 6, 2019 by an out-of-network Physician.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care from November 7, 2018 through November 14, 2018.
You asked the Plan to waive the copayment for inpatient mental health 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). According to your policy, there is a $320 copayment per day for days 1-5 and a $1,600 out of pocket limit per stay. You were inpatient for 7 days, however, you had consecutive inpatient stays November 4, 2018 through November 6, 2018 under claim 20183551808100 which took $960.00 copayment and appealed claim for dates of service November 7, 2018 through November 14, 2018 under claim 20183551807502 which took $640.00 copayment. $960.00+ $640.00 = $1,600.00. 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 inpatient mental health care from November 7, 2018 through November 14, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs respiratory care. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for pneumonia. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned from the ventilator to a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 31, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 31, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe PT services provided on June 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe PT services. You say that the employee that handled this case was not aware of the process.The Plan denied your request. The Plan says utilization of in-network providers is required unless the Plan pre-approves out of network services in non-emergent situations.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 PT services provided on June 25, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT scan of the thorax.You asked the Plan to pre-approvethe CT scan. The Plan denied your request. The Plan says the records do not show the enrollee has signs or symptoms that her disease has come back.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the CT scan. Our physician reviewer found that the enrollee is noted to have endometrial cancer, for which she has undergone surgery and radiation therapy. It does not appear that the enrollee is currently receiving any sort of chemotherapy or medication for the cancer. There appears to be no evidence of lung involvement from the cancer. As of December 2019, there was no documentation of significant respiratory symptoms, abnormal examination findings or abnormal CXR findings. As such, the requested CT of the chest is not shown to be currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the thorax.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the iWalk 2.0 Hands Free Crutch purchased on October 18, 2019.
You asked the Plan to reimburse you for the iWalk 2.0 Hands Free Crutch. You say that you needed the iWalk 2.0 Hands Free Crutch sooner than going through a contracted DME supplier. The Plan denied your request. The Plan says the website is not a Medicare certified supplier and your prescription was dated after the date of purchase.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to reimburse you for the iWalk 2.0 Hands Free Crutch purchased on October 18, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the core build up. We decided that the Plan does not have to pre-approve the retainer crowns and pontic.
You asked the Plan to pre-approve retainer crowns and a pontic. You say that you previously received these services in 2017 to 2019 and they were covered. You say that you were advised this matter was resolved with the dentist's office in November 2019. You also say that the dentist only crowned your teeth and did not put any screws in your teeth. The Plan says that the requested dental 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.
We decided that the Plan has to pre-approve the core build up. Core build up is listed as a covered service. Therefore, we decided that the Plan has to pre-approve the core build up.
We also decided that the Plan does not have to pre-approve the retainer crowns and pontic. Though the Plan offers a dental benefit in excess of Medicare coverage, porcelain retainer crowns and a porcelain pontic are not listed as covered services. Therefore, we decided that the Plan does not have to pre-approve the retainer crowns and pontic.