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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says there is no need for comprehensive or intensive therapy.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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on July 29, 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 code 95937 is 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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.We find that CPT code 95937 is not supported in themedical record. Specifically, the records show that train of four testing was performed and there is a more specific code for these services. 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 services rendered to the enrollee on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit rendered to the enrollee on September 4, 2019.You asked thePlan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99203 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 codeis payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 99203 and 01480. Code 99203 is a column II code with a modifier indicator of 1 when billed with column I code 01480. Code 99203 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe office visit rendered to the enrollee on September 4, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Denosumab injection (J0897, 96401) to be provided by an out of network (OON) provider..
You asked the Plan to pre-approve the injection. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available that can 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 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 the Denosumab injection (J0897, 96401) to be provided 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 the ED visit provided on September 26,
2019.
You asked the Plan to waive the copayment for the ED visit. You say that if you weren't taken off your
medication you would not have had these expenses. You say that you shouldn't have to pay the bill. 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 $90
copayment for each hospital emergency room visit.
You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care"
benefit category. The records show that you were treated in the ED. 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 ED visit provided on September 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided from September 4, 2019 through October 30, 2019.
You asked the Plan to waive the copayment for occupational therapy. You say that the therapy was provided at an outpatient hand clinic. You say that you were informed the copayment would be $10 per session. The Plan denied your request. The Plan says the copayments 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 $40 copayment for occupational therapy at an in-network outpatient hospital You have been asked to pay a total of $527.31 for occupational therapy.
Date of Service
Service
Standard Copayment
Member Liability
September 4, 2019
Occupational Therapy
$40
$40
September 6, 2019
Occupational Therapy
$40
$40
September 16, 2019
Occupational Therapy
$40
$40
September 17, 2019
Occupational Therapy
$40
$40
September 19, 2019
Occupational Therapy
$40
$40
September 23, 2019
Occupational Therapy
$40
$40
September 25, 2019
Occupational Therapy
$40
$40
September 30, 2019
Occupational Therapy
$40
$40
October 2, 2019
Occupational Therapy
$40
$40
October 7, 2019
Occupational Therapy
$40
$40
October 9, 2019
Occupational Therapy
$40
$40
October 14, 2019
Occupational Therapy
$40
$40
October 16, 2019
Occupational Therapy
$40
$40
October 21, 2019
Occupational Therapy
$40
$7.31-Met Maximum OOP
October 23, 2019
Occupational Therapy
$40
$0
October 28, 2019
Occupational Therapy
$40
$0
October 30, 2019
Occupational Therapy
$40
$0
TOTAL:
$527.31
Occupational therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that the occupational therapy was billed by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy provided from September 4, 2019 through October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe myocardial perfusion imaging provided on October 15, 2019.You asked the Plan to waive the coinsurance forthe myocardial perfusion imaging. You say that you were informed your copayment would only be $95. You say that you were not informed of a change in the cost.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered radiological diagnostic service. Covered services include specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures. You have been asked to pay $228.01, which is 20% of the allowed amount for the myocardial perfusion imaging. The allowed amount is $1,140.03 (20% x $1,140.03 = $228.01). The myocardial perfusion imaging falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefitcategory. The myocardial perfusion imaging is considered a nuclear medicine study. 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 forthe myocardial perfusion imaging provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on July 1, 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 code 63091 is 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 63091 is removal of middle, lower, or sacral spine bone with release of spinal cord or nerves, transperitoneal or retroperitoneal approach.We find that CPT code 63091 is not supported in the medical record. Specifically, the operative report does not contain documentation of a partial or complete vertebral cropectomy. 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 services rendered to the enrollee on July 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from acute rehab to optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the enrollee's needs are not inherently complex, and do not require an interdisciplinary approach.
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 physician reviewer found that the enrollee was medically reasonably stable and does not need acute rehab nursing care. He may benefit from further physical and occupational therapy, but does not require an intensive therapy program as he is unable to endure more than 30 minutes of therapy without rest breaks. Therefore, an IRF admission is not medically necessary based on his current functional status and medical stability with orthostatic hypotension. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on July 26, 2019 to July
28, 2019.
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 procedure code 19367 is not payable.
The Plan must follow Medicare rules. The rules say that CMS does not pay for an "inpatient-only" service
furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient
hospital bill type (TOB 13X).
We looked at the file and Medicare rules. The provider submitted a claim for procedure code 19367. This code
is an inpatient only code and was billed on an outpatient claim. Therefore, we decided that the Plan does not
have to pay for the services rendered to the enrollee on July 26, 2019 to July 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for monitored anesthesia services provided to the enrollee on August 28, 2019 and billed under codes 99152.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99152-59 (1 Unit) remains not supported. CPT 99152 represents Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the level of consciousness and physiological status. The documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the enrollee. Of note, an independent trained observer is someone other than the physician performing the services. It is noted that multiple attempts were made to contact the provider for additional information.
The Plan must follow Medicare rules. Medicare requires providers to submit claims with the appropriate codes and to submit medical records to support the codes bill. We find that CPT code 99152 is not supported in the by the medical records provided. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for monitored anesthesia services provided to the enrollee on August 28, 2019 and billed under codes 99152.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on August 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that it is the skilled nursing facility's responsibility to get prior authorization.The Plan denied your request. The Plan says no prior authorization was obtained for these services.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 ofarea 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 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 forskilled nursing services provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal cord decompression for the enrollee.You asked the Plan to pre-approve the surgery. You say that this is medically necessary.The Plan denied your request. The Plan says there is no clear imaging showing nerve root compression, no formal conservative routes noted, and no clear indication of acute radiculopathy on nerve conduction test noted.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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no red flags for surgery. There is no documentation of failure of conservative measures for back pain.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 surgery have not been met.Therefore, we decided that the Plan does not have to pre-approve spinal cord decompression for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that authorization was not obtained before you received the services. 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider, nor are they your primary care physician. 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 April 9, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the cystoscopy. We decided that the Plan does not have to waive the copayment for kidney stone procedure.
You asked the Plan to waive the copayment for the cystoscopy and the kidney stone procedure. You say that you were not informed that you would have to pay two copayments because two procedures were performed at the time of surgery. The Plan says that you have been charged the correct cost sharing amount.
We decided that the Plan has to reduce the copayment for the cystoscopy.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the surgical procedure was performed an at ambulatory surgical center.
The Plan says that you must pay a $285 copayment for the cystoscopy. Based on the plan contract, however, you cannot be asked to pay more than a $245 copayment for the cystoscopy. Therefore, we decided that the Plan has to reduce the copayment for the cystoscopy from a $285 copayment to a $245 copayment.
We also decided that the Plan does not have to waive the copayment for kidney stone procedure.
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 $245 copayment for the kidney stone procedure. The record shows the services are considered separate surgical procedures. Therefore, we decided that the Plan does not have to waive the copayment for kidney stone procedure.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on November 7, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you have been charged the correct cost sharing amount. The Plan denied your request. The Plan says a $90 copayment
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 $90 copayment for each hospital emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit 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 the emergency room visit provided on November 7, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forthe electrocardiogram (EKG) rendered to the enrollee on September 11, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says that only one interpretation of an EKG report is allowed per date of service in the emergency room (ER).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.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 states that only one EKG interpretation is allowed in the ER per date of service; however, the file shows that only one code (93010) was billed for the date of service at issue. The Plan has not provided any documentation to show that an EKG was billed more than once for this date of service.Therefore, we decided that the Plan has to pay forthe electrocardiogram (EKG) rendered to the enrollee on September 11, 2018.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 toopen the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided by the lab on October 15, 2019.
You asked the Plan to pay for screening tests. You say that you are appealing with records to support the necessity of these services. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the diagnoses listed and were performed for screening purposes.
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 tests at issue in this appeal, genetic screening tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided by the lab on October 15, 2019.