Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on January 9, 2020and billed under code 70450.You asked the Plan to pay for these services. You say that this claim should be paid.The Plan denied your request. The Plan says this service was previouslypaid to a physician in the same group for the same date of servicefor the same enrollee. Maximus overturned he Plans denial. The Plan requested a reopen and stated that this claim denied because the Plan previously paid for this service under another claim. The Plan states that a provider in the same group billed the same enrollee for the same service and the same date of service. Both providers also practice under the same physician group. The Plan states that the rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. The Plan states this claim cannot be paid as billed due to the association with the previous claim submitted. The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim in question cannot be paid as billed under Medicare billing guidelines. The Plan has submitted claims to show these services were previously paid under another claim from a physician of the same group. Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on January 9, 2020 and billed under code 70450.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 29, 2020.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 Plandid not pre-approve the physician's services. 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 June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on September 1, 2020, to October 13, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with these copayments. 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 $20 copayment for physician/practitioner services/specialists. You have been asked to pay a $20 copayment for a specialist office visit. The total amount you are being asked to pay is $60 ($20 x 3 visits = $60). A specialist office visit falls within the physician/practitioner services/specialists 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 specialist office visit provided by a participating provider on September 1, 2020, to October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for partial excision and manual prep of drug delivery provided
on February 12, 2020.
You asked the Plan to pay for partial excision (24147) and manual prep of drug delivery (20700). You say that
the Plan should pay this claim. The Plan denied your request. The Plan says these procedures are part of the
global fee and previously paid.
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 records provided do not support that this service was a separate and distinct service from the
claim submitted by a provider of the same group, for the same enrollee for the same service. Medicare billing
criteria are not met. Based on this information, we decided that Medicare rules for coverage of partial excision
(24147) and manual prep of drug delivery (20700) have not been met. Therefore, we decided that the Plan does
not have to pay for partial excision and manual prep of drug delivery provided on February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by American Medical Response on June 23, 2020.You asked the Plan to pay forthe ambulanceservices. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by American Medical Response on June 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from
January 14, 2021, and forward.
You asked the Plan to pre-approve the continuation of inpatient mental health care. You say that the
continuation of inpatient mental health care from January 14, 2021, and forward is medically necessary. The
Plan denied your request. The Plan says the continuation of inpatient mental health care from January 14, 2021,
and forward is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continuation of inpatient mental
health care. Our reviewer says that the continuation of inpatient mental health care from January 14, 2021, and
forward is not medically necessary. Our physician reviewer found this enrollee did not require inpatient mental
health treatment beyond the dates in question as he was not a danger to himself or others and did not have any
delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the
date in question. It did not appear that the services for the dates in question were reasonably expected or
medically necessary to improve the enrollee's condition or for the purpose of diagnosis. It appears that the
services were supervised and evaluated by a physician. Based upon review of the records provided, this
enrollee does not meet the criteria for treatment in an acute inpatient mental health unit beyond the date in
question of January 14, 2021, and forward and the enrollee can be treated in a lesser restrictive setting as he
was not showing any active suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was
not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats
to safety.
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 continuation of inpatient mental health care have not been met. Therefore,
we decided that the Plan does not have to pre-approve the continuation of inpatient mental health care from
January 14, 2021, and forward.
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 requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must followMedicare 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 thePlan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is at an assisted living facility with stable comorbidities including atrial fibrillation on anticoagulant therapy, neuropathy, heart disease, chronic pain, osteoporosis, dementia, and urinary incontinence who has a urinary tract infection and has a walking boot due to a metatarsal fracture but is primarily in a wheelchair due to frequent recent falls. The records document that the enrollee has stable medical conditions but requires physical and occupational therapy due to the foot fracture.While the enrollee requires two modalities of rehabilitation because of her foot injury, she does not have the complexities of nursing and medical care that requires inpatient rehabilitation care services. The enrollee does not require medical supervision in an inpatient rehabilitation facility and a lower level of care is appropriate.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: Testing
Decision: Unfavorable

Wedecided that the Plan does not have to waive the deductible for diagnostic testing provided by a non-participating provider on March 31, 2019.You asked the Plan to waive the deductible for diagnostic testing. You say that this provider should be in-network. The Plan denied your request. The Plan says the correct deductible has been applied.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 there is a $975 copayment for outpatient diagnostic tests. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 copayment for outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time diagnostic testing was received on March 31, 2019. The total amount you are being asked to pay is $685.35. Therefore, we decided that the Plan does not have to waive the deductible for diagnostic testing provided by a non-participating provider on March 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approveVertiflex. You say that you have been in pain with significant spinal stenosis at multiple levels.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this service is experimental/investigational.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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of large-volume, long-term peer-reviewed outcome studies to support the use of this device for your condition. There is no discussion in the record of spinal instability on flexion/extension. The requested Vertiflex would not be considered the standard of care for your condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist services and electrocardiogram (EKG) rendered from February 17, 2020 to March 24, 2020.You asked the Plan to waive the copayments forthese services. You say that you disagree with the charges.The Plan denied your request. The Plan says the copayments were 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 $35 copayment for services obtained from a specialist and a $20 copayment for Medicare-covered non-radiological diagnostic services, including EKGs.Review of the file shows that you received specialist services for four dates of service from February 17, 2020 to March 24, 2020. You have been asked to pay a $35 copayment per date of service for these services, for a total of $140. These services fall within the services obtained from a specialist benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The file shows that you had an EKG on February 26, 2020. You have been asked to pay a $20 copayment for these services.These services fall within the Medicare-covered non-radiological diagnostic services, including EKGs, benefit category. This means that you have been asked to pay the correctamount based on your contract with the Plan.The total amount you have been asked to pay for these services is $160.00. 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 forthe specialist services and electrocardiogram (EKG) rendered from February 17, 2020 to March 24, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services to be provided by an oral surgeon.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental
services when they are provided by a participating general dentist.
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 services. Our reviewer says that
Our physician reviewer found
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve dental services to be provided by an oral surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for9 days of skilled nursing facility services provided during the stay January 1, 2020, to January 17, 2020.You asked the Plan to waive the copayment for9 days of skilled nursing facility services. You say that you were told there would be no copayment.The Plan denied your request. The Plan says you were charged this copayment 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 $160 copayment each day for days 21-45for skilled nursing facility services. You have been asked to pay a $160 copayment each day for 9 days of skilled nursing facility services. The 9 days of skilled nursing facility services falls within the days 21-45 of Skilled Nursing Facility Care benefit category. The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services, a benefit period begins the day you're admitted as an inpatient in a hospital or SNF. The benefit period ends when you haven't gotten any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. The benefit period is not tied to the calendar year. his 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 for9 days of skilled nursing facility services provided during the stay January 1, 2020, to January 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services provided by a participating provider on August 20, 2020.You asked the Plan to waive the copayment forradiology services. You say that you already have a low income and having this additional fee is too much. 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 $150 copayment for outpatient diagnostic tests/radiology service. You have been asked to pay a $150copayment for radiology services. The correct copayment has been applied to the services that were provided. Radiology services fall within the outpatient diagnostic tests/radiology service 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 radiology services provided by a participating provider on August 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on
August 17, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for this service was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on August 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for care for multiple traumatic injuries (including grade 3 liver laceration, grade 1 splenic laceration, multiple rib fracture, compression fracture, pelvic fracture requiring surgical repair) after a fall from height. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99222) provided on
September 14, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was
submitted untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for this service was not filed until September 18, 2020. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the initial hospital care, per day (99222) provided on September 14, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient hemodialysis treatments to be providedby the out-of-network provider.You asked the Plan to pre-approve the outpatient hemodialysis treatments. The Plan denied your request. The Plan says outpatient hemodialysis treatments are covered services if performed in an in-network facility.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 outpatient hemodialysis treatments to be providedby the out-of-network provider.