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

We decided that the Plan has to pre-approveskilled nursing facility (SNF) care for the enrollee.You asked the Plan to pre-approveSNF care. You say that SNF admission is medically necessary.The Plan denied your request. The Plan says that Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that Medicare coverage criteria are met. Our physician reviewer found thedocumentation supports that skilled therapy services are medically reasonable and necessary for the enrollee in this case.The documentation supports that the skilled therapy services on a daily basis are medically reasonable and necessary for this enrollee, given the degree of deconditioning and debility.Medicarecoverage criteria for SNF admission are met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care for the enrollee.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 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 medical services provided on July 7, 2020 by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on February 25, 2020.You asked the Plan to waive the copayment for an emergency room visit. You say that you were unaware that there would be a copayment. 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 $50 copayment for emergency care. You have been asked to pay a $50 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An 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 an emergency room visit provided by a participating provider on February 25, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for bronchoscopies (31629, 31624) provided on June 30, 2020.
You asked the Plan to pay for bronchoscopies. You say that these codes are supported in the records. The Plan denied your request. The Plan says these codes are not documented.
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 31629 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i); and 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage. We find that CPT code 31629 and 31624 is not supported in the medical record. Specifically, the procedure note for this date of service was not included in the file. The submitted medical records do not document a needle aspiration biopsy or bronchial alveolar lavage. Based on this information, we decided that Medicare rules for coverage of bronchoscopies have not been met. Therefore, we decided that the Plan does not have to pay for bronchoscopies (31629, 31624) provided on June 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services (99335) provided October 31, 2019.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim cannot be paid as 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.We find that CPT code 99335 is not supported in the medical record. Specifically, the claim was billed using Place of Service 33-Custodial Care Facility, however the records show the enrollee was at a Skilled Nursing Facility at the time services were provided. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.Therefore, we decided that the Plan does not have to pay forphysician services (99335) provided October 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient hospital facility services provided from November 18, 2019, through November 21, 2019.You asked the Plan to waive the copayment forthe outpatient hospital services. You say that the enrollee met all of the criteria for inpatient admission, so this copayment should be removed.The Plan denied your request. The Plan says this copayment was charged correctly.  The records clearly show that the enrollee was in an outpatient status at the hospital.  This status is not affected by the patient's diagnosis.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment for outpatient hospital services. The enrollee has been asked to pay a $400 copayment for the outpatient hospital services. The records clearly show that she was never admitted as an inpatient, but rather kept in observation, which is an outpatient status. Thismeans that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have towaive the copayment foroutpatient hospital facility services provided from November 18, 2019, through November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on August 17, 2020.You asked the Plan to waive the copayment for specialist services. You say that you do not agree with this copayment. 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 $35 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay a $35 copayment for specialist services. Specialist services fall within the physician/practitioner services/in-network/specialist 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 specialist services provided by a participating provider on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on June 18, 2020.You asked the Plan to waive the copayment for vision services. You say that you thought that this exam would be covered. The Plandenied 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 $40 copayment for vision care. You have been asked to pay a $40 copayment for vision services. The correct copayment has been applied to the services that were provided. Vision services fall within the vision 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 vision services provided by a participating provider on June 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (87640, 87652, 87653, 87799, 87900) provided March 17, 2020.You asked the Plan to pay forthe lab services. You say that the services were medically necessary.The Plan denied your request. The Plan says these services are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The lab services at issue in this appeal 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 forthe lab services (87640, 87652, 87653, 87799, 87900) provided March 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay provided from May 31, 2020, to June 30, 2020.You asked the Plan to pay forthe SNF stay. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says rules for SNF care have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay provided from May 31, 2020, to June 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora portable oxygen concentrator and shipping costs (E1390, 99199) provided July 9, 2020.You asked the Plan to pay forthe oxygen concentrator and shipping costs. You say that the oxygen equipment was medically necessary.The Plan denied your request. The Plan says purchased oxygen equipment is not covered.The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is covered. We looked at the file and Medicare rules. The oxygen equipment was purchased. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator and shipping costs have not been met.Therefore, we decided that the Plan does not have to pay fora portable oxygen concentrator and shipping costs (E1390, 99199) provided July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right rotator cuff shoulder surgery for the enrollee.
You asked the Plan to pre-approve right rotator cuff shoulder surgery. You say that this service is medically necessary. The Plan denied your request. The Plan says medical necessity has not been established.
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 right rotator cuff shoulder surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a 3-month trial and failure of physical therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of right rotator cuff shoulder surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve right rotator cuff shoulder surgery for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

vWe decided that the Plan does not have to waive the deductible forphysical therapy provided from November 21, 2018, through December 28, 2018.You asked the Plan to waive the deductible forphysical therapy. You say that you were informed a mistake had been made and to not pay the bills. You say that all of the claims were denied but your deductible was paid in full.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your combined deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to outpatient therapy. This cost sharing is a contractual obligation that had not beenmet at the time physical therapy was received on November 21, 2018, November 27, 2018, December 6, 2018 and December 28, 2018.Therefore, we decided that the Plan does not have to waive the deductible forphysical therapy provided from November 21, 2018, through December 28, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 14, 2020.
You asked the Plan to pay for the medical services. You say that these services were rendered in accordance with the referring provider's orders and they were medically necessary. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered by the Plan. The Plan says that the rendering and referring provider did not become a plan provider until May 16, 2020, which is after the date of service at issue in this appeal.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services provided on May 14, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forlaboratory services (82247, 84460, 86603) provided on July 22, 2020.You asked the Plan to pay forlaboratory services. You say that this was billed correctly.The Plan denied your request. The Plan says that the billed place of service is inconsistent with the enrollee's inpatient status.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 denyyour request. Although the Plan's denial states that the billed place of service is inconsistent with the enrollee's inpatient status, the submitted case did not include the claim for the services at issue showing how they were billed and did not includedany documentation showing that the enrollee was inpatient at the time these services were rendered.Therefore, we decided that the Plan has to pay forlaboratory services (82247, 84460, 86603) provided on July 22, 2020.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 foran emergency room visit on August 5, 2020.You asked the Plan to pay foran emergency room visit. You say that these emergency services were medically necessary.The Plandenied your request. The Plan says the hospital is not properly certified with Medicare.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Specifically, the services at issue were provided by a provider that appears to not be certified for Medicare. The provider at issue did not come up on a Medicare.gov search for hospitalproviders serving the enrollee's area. There was no documentation supplied by the provider to verify that they are certified by Medicare.Therefore, we decided that the Plan does not have to pay foran emergency room visit on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 14, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that the doctor shouldn't be penalized for the facility's failure to get authorization.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on July 14, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found theenrollee does not require skilled nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.  The enrollee is asymptomatic and does not have complex wound care, IV antibiotics, nebulizer treatments, or other SNF level SN need. The enrollee's functional level  does not require  skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist  to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services rendered by an out-of-network provider on May 14, 2020.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 an out-of-network provider without prior authorization.The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them.Therefore, we decided that the Plan does not have to pay forthe medical services rendered by an out-of-network provider on May 14, 2020