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

We decided that the Plan does not have to waive the copayment for SNF care from January 1, 2020 through January 25, 2020 provided an out-of-network provider. 
 
You asked the Plan to waive the copayment for SNF care. You say that you are appealing your cost-share responsibility for the services you received because you did not receive the care you needed. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 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 show that you received SNF care from January 1, 2020 through January 25, 2020 by an innetwork provider. Your first two days, December 30 and 31, 2019 with the provider you were assessed a $0 copayment. The next 18 days, January 1, 2020 through January 18, 2020 with this provider also assessed a $0 copayment. The next six (6) days, January 19, 2020 through January 25, 2020 with this provider assessed $160 X 6 = $960 copayment. Therefore, your total cost-share responsibility is a $960 copayment for the SNF care. Your EOC states, enrollees must pay a $0 copayment each day for days 1 to 20, then a $160 copayment each day for days 21 to 51 for in-network SNF care and $0 copayment for additional Medicare-covered days, up to 100 days. 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 SNF care from January 1, 2020 through January 25, 2020 provided an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 17, 2020. 
 
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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 16, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 for the drug testing rendered on December 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent detection testing provided on March 10,
2020.
You asked the Plan to pay for laboratory test. You say that you only perform this test in your hospital lab. The
Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not
covered by Medicare.
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 pay for laboratory test. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there was no specific clinical rationale provided for the testing performed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of laboratory test have not been met. Therefore, we decided that the Plan does not
have to pay for infectious agent detection testing provided on March 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.
You asked the Plan to pre-approve home health care. You say that it is difficult to leave the house and physical therapy offices are unwilling to see you, so home health physical therapy is the only option. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because there are no orders for home health physical therapy and you are not homebound.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home health care. Our reviewer says that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found the documentation does not support that you are confined to the home, or that you are receiving services under a plan of care established and periodically reviewed by a physician. The needs for skilled nursing care and skilled therapy care are not established in the medical records.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on November 20, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were told there was a $45 copayment. You say that you cannot afford the additional cost. 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 $225 copayment for each Medicare-covered advanced imaging service from an in-network provider. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 CT scan provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 1, 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 there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. 
 
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the laboratory services rendered on November 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from December 28, 2019 to December 30, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the Plan should pay this claim. The Plan denied your request. The Plan says self-administered drugs are not covered under your Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from December 28, 2019 to December 30, 2019.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus and diphtheria toxoids vaccine (90714) provided on
January 7, 2020.
You asked the Plan to pay for a tetanus and diphtheria toxoids vaccine. You say that it was not clear to you that
this would not be covered. The Plan denied your request. The Plan says this vaccine is covered under your
Medicare Part D benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus and
diphtheria toxoids vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a tetanus and
diphtheria toxoids vaccine. Therefore, we decided that the Plan does not have to pay for a tetanus and
diphtheria toxoids vaccine (90714) provided on January 7, 2020.
Benefits for a tetanus and diphtheria toxoids vaccine may be available under Medicare Part D. Contact the Plan
that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you are appealing with supporting medical records. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, skin care, and daily therapy can be provided at a SNF. In this case, the enrollee is
mostly minimal assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer
duration of therapy will allow for measurable gains to be attained within a predicted and reasonable 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for SNF care provided to the enrollee from August 15, 2019 through August 31, 2019.
You asked the Plan to waive the cost-share for SNF care. You say that you are appealing the member's cost-share responsibility for the services the member received. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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). There is no coinsurance, copayment, or deductible for days 1-20 of each Medicare-covered stay at a SNF. The enrollee pays a $75 co-pay per day for days 21-65." The member stayed at a SNF from June 11, 2019 to June
30, 2019 equaling to 20 days. From July 1, 2019 to July 19, 2019, the enrollee stayed at the facility for total 18 days and the enrollee was charged $1,350 at $75 copayment per day. This amount is the enrollees co-pay and it was counted towards to enrollee's Maximum Out of Pocket (MOOP). From days August 1, 2019 to August 31, 2019 the enrollee stayed at the SNF for another 31 days. The enrollee was charged at $75.00 co-payment a day and the total amount is $2.050. The charge was reduced to $1,660 because the enrollee had partially met the $3400 MOOP. This means 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 to waive the cost-share for SNF care provided to the enrollee from August 15, 2019 through August 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 16, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 for the drug testing rendered on October 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Carboplastin, and Avastin for the enrollee.
You asked the Plan to pre-approve the drugs. You say that the enrollee is due for chemotherapy, and was diagnosed with PDL 1 recently. The Plan denied your request. The Plan says this drug combination is not compendia supported for treatment of non-small-cell lung cancer.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drugs. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the submitted information indicates the enrollee has advance non-small cell lung cancer (NSCLC). The submitted documents do not include results of ALK, EGFR, or other mutation testing. The CMS approved compendia do not support the use of this combination to treat NSCLC. The NCCN Guidelines Version 6.2020 Non-small cell lung cancer do not include this combination. Therefore the documentation does not support that the requested combination is medically reasonable and necessary nor that it is safe and effective for the enrollee. 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 drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Carboplastin, and Avastin for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Reclast injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that services that are not medically necessary are not covered under the benefit plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found Zometa (Reclast) is FDA approved for the treatment and prevention of osteoporosis in postmenopausal females. This enrollee has osteoporosis based on her most recent DEXA scan and is on calcium and vitamin D. The service is reasonable and medically necessary as well as safe and effective. 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Reclast injection 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 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 issue reimbursement for the office visit (99202) provided on February 3, 2020.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 this service is not a covered benefit under your contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to issue reimbursement for the office visit (99202) provided on February 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (9350) provided on August 9, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the billed code does not appropriately reflect the services provided.
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 99350 is home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family. We asked our coder 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 home visit. Our reviewer says that CPT code 99350 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided indicates that these services were performed by a resident nurse. The physician was not present at the time this service was performed We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not have to pay for a home visit (9350) provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation (92012) provided February 19, 2020.
You asked the Plan to pay for ophthalmology services. You say that this service was paid last year and you know that this is covered and you would like this reprocessed and paid. The Plan denied your request. The Plan says the provider has been informed that this service was billed incorrectly. No payment is needed from you.
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 92012 is Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment. We find that CPT code 92012 is not supported in the medical record. Specifically, two or more diagnosis codes associated to it are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available. Based on this information, we decided that Medicare rules for coverage of ophthalmology services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation (92012) provided February 19, 2020.