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

We decided that the Plan does not have to pay for a rest home visit (99335) provided on July 28, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for a rest home visit. You say that you are in network with most plans and was unaware that you were out-of-network with the member's specific plan. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 a rest home visit (99335) provided on July 28, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on March 18, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not 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 of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab work provided on March 18, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the swallow function testing you had on March 15, 2021.

You asked the Plan to waive the copayment for the swallow function testing. You say that you believe the services that you had on March 15, 2021, and March 22, 2021, were the same services, so the copayments should be the same. The Plan denied your request. The Plan says on March 15, 2021, you had a swallow function test. On March 22, 2021, you had a speech therapy evaluation, so these were different services. You were charged the copayment for the swallow function test 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 $30 copayment for outpatient diagnostic tests. 

You have been asked to pay a $30 copayment for the swallow function testing. The swallow function testing falls within the outpatient diagnostic tests 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 swallow function testing you had on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided during a colonoscopy on December 8, 2020, billed with code G0500.

You asked the Plan to pay for the moderate sedation services. You say that the sedation was clearly documented and was medically necessary for the procedure. The Plan denied your request. The Plan says the use of this code is not supported due to the absence of a trained observer.

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 G0500 is Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status.

We find that CPT code G0500 is not supported in the medical record. Specifically, the record do not document the presence of a trained independent observer as required by the code definition. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided during a colonoscopy on December 8, 2020, billed with code G0500.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on March 12, 2021.

You asked the Plan to waive the copayment for the ER visit. You say that you think this copayment should be waived because you had a loop monitor put on incorrectly that caused you to bleed and you had go to the ER to have it fixed. 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 $110 copayment for each emergency room visit. 

You have been asked to pay a $110 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit. 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 (ER) visit you had on March 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ophthalmic ultrasound and visual field test you had on February 8, 2021.

You asked the Plan to waive the copayments for the ophthalmic ultrasound and visual field test. You say that your funds are limited so you cannot pay this copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that a $25 copayment applies to the visual field testing and an $8- copayment applies to the ultrasound. However, the Plan has only charged you a $5 copayment for this ultrasound, but future ones will be subject to the $80 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 $25 copayment for non-radiological diagnostic services and an $80 copayment for radiological diagnostic services (including ultrasounds).

You have been asked to pay a $25 copayment visual field test and a $5 copayment for the ophthalmic
ultrasound. The visual field test falls within the non-radiological diagnostic services benefit category and the
ophthalmic ultrasound falls in the radiological diagnostic services benefit category. 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 for the ophthalmic ultrasound and visual field test you had on February
8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a dermatologist on April 16, 2021 to remove sutures.

You asked the Plan to waive the copayment for the dermatology visit. You say that you have never had to pay to get sutures removed before. The Plan denied your request. The Plan says you were charged this amount correctly. The Plan says that because the allowed amount for this service ($21.64) is less than your copayment obligation, you are responsible for the full allowed amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for visits with a specialist. 

You have been asked to pay a $40 copayment for the dermatology visit. This copayment applies regardless of how long the visit lasts. 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 office visit you had with a dermatologist on April 16, 2021 to remove sutures.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the transoral biopsy procedure you had on March 2, 2021, at an outpatient hospital facility.

You asked the Plan to waive the cost sharing for the transoral biopsy. You say that you did not know that this procedure would cost this much. The Plan denied your request. The Plan says you were charged this cost sharing 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 $750 deductible that applies to outpatient hospital services.

You have been asked to pay a $750 deductible for the transoral biopsy. The transoral biopsy falls within the outpatient hospital services benefit category, and the deductible applies to these services. You had not yet met this deductible on the date of service.. 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 cost sharing for the transoral biopsy procedure you had on March 2, 2021, at an outpatient hospital facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device for the enrollee.

You asked the Plan to pre-approve a CardioMEMs device. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the request is considered investigational and therefore not covered.

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 a CardioMEMs device. Our reviewer says that a CardioMEMs device is not considered medically reasonable and necessary in this case. Cardiomems pressure sensor monitoring device implantation has been FDA approved and has published literature to support its use in specific patients on fully tolerated guideline directed medical therapy who have NYHA Class III symptoms despite medical therapy and a hospitalization within the past 12 months for decompensated congestive heart failure (CHF). This patient has a history of ischemic cardiomyopathy but is being managed with clinical factors (weight and symptoms) and on her most recent evaluation had no signs of CHF on exam.

There are no reported hospitalizations for decompensated CHF in the past 12 months in the provided medical records and the specific symptoms and NYHA classification are not documented as well-- which are part of the FDA approved indications for the device. There are also limited records regarding frequency of medication titration and response to guideline directed therapy using standard clinical assessments as well. Based on the current records provided, she does not currently meet published or FDA approved indications for Cardiomems device implantation at this time. Our physician reviewer found that the enrollee's condition does not meet criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day (99221) rendered by the outof-
network provider on March 14, 2021.

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 was 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 service at issue in this appeal was not provided in an emergency or urgent care situation. The service was
not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have
to pay for the initial hospital care, per day (99221) rendered by the out-of-network provider on March 14, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on February 16, 2021.

You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425). The Plan denied your request. The Plan says that the information submitted does not support this many/frequency of services. The patient's claims history indicates they were in an inpatient hospital 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 deny your request. Specifically, the Plan has not submitted the hospital/facility medical records to substantiate this denial. Therefore, we decided that the Plan has to pay for ambulance service, basic life support, emergency transport (A0429) and ground mileage (A0425) provided on February 16, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an above-knee disarticulation socket (L5650), an above-knee molded socket with endoskeletal single axis knee-shin system and SACH foot (L5321), an above-knee test socket (L5624), and an above-knee acrylic socket (L5631).

You asked the Plan to pre-approve an above-knee disarticulation socket, an above-knee molded socket with endoskeletal single axis knee-shin system and SACH foot, an above-knee test socket, and an above-knee acrylic socket. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested items are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a determination of the medical necessity for certain components/additions to the prosthesis is based on the enrollee's potential functional abilities. The rules also say that items coded L5624 and L5631 are not 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 an above-knee disarticulation socket and an above-knee molded socket with endoskeletal single axis knee-shin system and SACH foot. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the most recent medical document in the case record indicates that the enrollee requires a maximum assist for transfers and that on July 23, 2021, the enrollee was transferred to the hospital with altered level of consciousness. The documentation does not support that the enrollee can currently use the requested items safely or that the enrollee's functional level is appropriate for the requested items. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an above-knee disarticulation socket, an above-knee molded socket with endoskeletal single axis knee-shin system and SACH foot, an above-knee test socket, and an above-knee acrylic socket have not been met. Therefore, we decided that the Plan does not have to pre-approve an above-knee disarticulation socket (L5650), an above-knee molded socket with endoskeletal single axis knee-shin system and SACH foot (L5321), an above-knee test socket (L5624), and an above-knee acrylic socket (L5631).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the transthoracic echocardiography (TTE) and the duplex scan of the cranial arteries you had on September 29, 2020.

You asked the Plan to waive the copayments for the TTE and the duplex scan. You say that you have not had to pay a copayment for these tests before and you cannot afford this. The Plan denied your request. The Plan says your benefits changed between 2019 and 2020. Based on your 2020 benefits, you were charged these copayments correctly. For the TTE, the allowed amount for this procedure ($147.94) is less than your copayment amount, so you are responsible for the full allowed amount for this service.

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 $155 copayment for each radiological diagnostic service.

You have been asked to pay a $155 copayment for the TTE and a $155 copayment for the duplex scan. Both of these tests fall within the radiological diagnostic 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 copayments for the transthoracic echocardiography (TTE) and the duplex scan of the cranial arteries you had on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services.

You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary. You are undergoing a planned total knee arthroplasty. You are medically stable and have been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the Centers for Medicare & Medicaid Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation you will require a greater than 2 midnight stay. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient hospital services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on January 23, 2021.

You asked the Plan to pay for the critical care services. You say that these services are supported. The Plan
denied your request. The Plan says no time was documented in the record. As such, no payment can be made.

The Plan must follow Medicare rules. Medicare rules say that critical care progress notes must document the
time spent providing the services.

In this case, the total time spent is not documented. Based on this information, we find that the Medicare
coverage rules for these services have not been met. Therefore, we decided that the Plan does not have to pay
for the critical care services provided on January 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you need the support of a SNF to fully recover. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the requested SNF care is not medically reasonable and necessary in this case. Our physician reviewer found that there are no medical records stating details of your stroke and comorbid conditions. You are medically stable. You have no daily skilled nursing needs nor do you require daily skilled therapy services on an inpatient basis. 

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 not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.