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

We decided that the Plan does not have to waive the coinsurance for initial observation care provided on September 24, 2019.
You asked the Plan to waive the coinsurance for initial observation care. You say that you were in the hospital on this date and paid the hospital copayments. You say that you are not responsible for the doctor bills. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each in-network surgical or observation room service you get at an outpatient hospital. You have been asked to pay $26.97, which is 20% of the allowed amount for initial observation care. The allowed amount is $134.83 (20% x $134.83 = $26.97). Initial observation care falls within the "Outpatient hospital services" 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 coinsurance for initial observation care provided on September 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the lower extremity (73721) provided October 28, 2019 by providor.You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waved.The Plan denied your request. The Plan says the correct cost-sharing was 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 $225 copayment for diagnostic radiology. You havebeen asked to pay a $219.60 copayment for the MRI. The MRI falls within the diagnostic radiology benefit category. The allowable amount of $219.60 is less than the copayment stipulated in the contract, so this amount was applied instead. 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 Magnetic Resonance Imaging (MRI) of the lower extremity (73721) provided October 28, 2019 by provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve audio automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve audio automatic blood pressure monitor. You say that you need an audio blood pressure monitor because you are legally blind and your cardiologist wants you to check your blood pressure every day due to your diagnosis of atrial fibrillation. The Plan denied your request. The Plan says the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve audio automatic blood pressure monitor (A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or
heat exchanger (99190) provided from October 24, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You
say that this was a mandatory service. The Plan denied your request. The Plan says payment for this service is
included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190)
provided from October 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you are unable to get out of bed by yourself. The Plan denied your request. The Plan says you have reached your maximum functional level.
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. Continued services beyond March 27, 2020 were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you have stable vital signs, and were treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a modified assist level with bed mobility, and standby to contact guard assist with transfers and gait. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 you are requesting a short inpatient stay at a rehab facility in order to work on balance, coordination and ambulation and to make an attempt at learning to cope with chronic lower back pain. The Plan denied your request. The Plan says treatment in an acute rehab facility 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly moderate assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 16, 2019.
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 Plan did not pre-approve the services 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 for physician's services provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered to enrollee on September 14, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 00910 was billed with an inappropriate modifier.The Plan must follow Medicare rules. The rules say that use of the "-22" modifier applies to procedures with a zero-day postoperative period.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 00910-22. This code does not have a global postoperative period; therefore, the use of the 22 modifier is incorrect. 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 anesthesia services rendered to enrollee on September 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided at an ambulatory surgical center on December 27, 2019.
You asked the Plan to waive the copayment for a cataract surgery. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $300 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $300 copayment for a cataract surgery. A cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgery provided at an ambulatory surgical center on December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pre-approve diagnostic facet blocks.
You asked the Plan to pre-approve the diagnostic facet blocks. You say that you have clearly met all of the conditions required for coverage. You say that you are in a lot of pain and require the injections being requested. The Plan denied your request. The Plan says that the criteria for coverage have not been met because there is no documentation of inadequate response to conservative care, such as non-steroidal anti-inflammatory drugs, acetaminophen, and physical therapy. The enrollee's clinical condition does not show to meet the guidelines for use of this treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 diagnostic facet blocks. Our reviewer says that facet blocks are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with chronic low back pain, has had multiple vertebral body fractures, and had vertebroplasties. The enrollee also had spinal surgery. The enrollee is currently taking Morphine, Cymbalta, Baclofen and Diclofenac. The enrollee has had physical therapy. The enrollee has had an epidural steroid injection which gave her 50% pain relief. The enrollee has also had SI joint injections as well as RF. The enrollee has failed conservative therapy and has continuing pain after an epidural steroid injection. 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 diagnostic facet blocks have been met. Therefore, we decided that the Plan has to pre-approve diagnostic facet blocks.
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 for the medical services provided on November 12, 2019 by a non-network provider.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 the services were rendered by a non-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 has network providers available who can provide 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 the medical services provided on November 12, 2019 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 27, 2019 to August 13, 2019 to the enrollee by an out of network (OON) provider.
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 the services were rendered 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 has network providers available who can provide 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. The Plan paid for the approved services rendered from July 27, 2019 to August 8, 2019. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 27, 2019 to August 13, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support the billed service.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skin substitute services (HCPCS Q4177) provided to the enrollee on October 24, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the service 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.In this case, the CPT Code Manual definition of HCPCS code Q4177 is "FlowerAmnioFlo, 0.1 cc." 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 services. Our reviewer says that the services at issue in this were not supported by the medical records submitted. Our physician reviewer found the medical records provided do not include documentation of the the dosage administered to the patient, therefore, Q4177 (20 units) cannot be verified 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 services have not been met.Therefore, we decided that the Plan does not have to pay for skin substitute services (HCPCS Q4177) provided to the enrollee on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for continuous glucose monitor supplies provided on October 31, 2019.
You asked the Plan to waive the coinsurance for diabetic supplies. You say that you were assured that this provider was in-network with the Plan. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct. The Plan also says that they have reprocessed this claim to approve additional payment, so you are only responsible for the in-network cost-sharing amount for this claim.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network continuous glucose monitor supplies. The allowed amount of the claim is $464.18, resulting in a coinsurance obligation of $92.84. You have been asked to pay 20% coinsurance for diabetic supplies. Diabetic supplies fall within the Diabetes Self-Management Training, Diabetic 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 coinsurance for continuous glucose monitor supplies provided on October 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services rendered to the enrollee on October 2, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes V2628 and V2623 are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code V2628 is fabrication and fitting of ocular conformer. The definition of code V2623 is prosthetic eye, plastic, custom. We find that CPT codes V2628 and V2623 are not supported in the medical record. Specifically, the documentation does not indicate that fabrication of fitting of ocular conformer was billed on the date of service at issue to support code V2628. The documentation does not indicate that a custom plastic prosthetic eye was fitted or dispensed to the enrollee to support code V2623. 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 vision services rendered to the enrollee on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mattress.
You asked the Plan to pre-approve a mattress. You say that this mattress was recommended by your PCP for you chronic back problems. The Plan denied your request. The Plan says this mattress is not specialized and specifically designed to solve a medical problem.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Mattresses are only covered for hospital beds. Therefore, we decided that the Plan does not have to pre-approve a mattress.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography (CT) scan of the head rendered to enrollee on November 7, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 70450 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without contrast material.We find that CPT code 70450 is not supported inthe medical record. Specifically, the file shows that the services were billed with an outpatient place of service code while the enrollee was under inpatient status. Based on this information, we decided that Medicare rules for coverage of these serviceshave not been met.Therefore, we decided that the Plan does not have to pay forthe computed tomography (CT) scan of the head rendered to enrollee on November 7, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you are a diabetic and almost died because of your extremely low blood sugar level. You say that the ambulance visit to your home was critical and lifesaving. You say that you live on minimal income and cannot afford the bill.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 October 24, 2019. 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.