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

We decided that the Plan does not have to pay for the home health services provided on October 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 home health services provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on March 9, 2020.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual preventive appointment. 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 $40 copayment for each specialist in-person office visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated and diagnostic laboratory services were performed during the office 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 office visit provided on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on December 19, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you were not given options and 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 $150 copayment for ambulance services. You have been asked to pay a $150 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound debridement provided on February
28, 2020.
You asked the Plan to waive the copayment for wound debridement. You say that you previously only paid
$20. You say that you have never paid this amount before. 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 per visit for Medicare-covered outpatient surgery or procedure at a hospital facility.
You have been asked to pay a $225 copayment for wound debridement. Wound debridement falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The wound debridement is considered a surgical service that was billed by the
hospital. 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 wound debridement provided on February 28,
2020.
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 medically 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 the enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee is high functioning and does not need IRF level of therapies. The enrollee may benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability.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 foran unclassified drug injection (J3490) provided on October 11, 2019.You asked the Plan to pay forthe unclassified drug injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this code is listed as an incidental item and is packaged into the APC rate.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 J3490 is not supported in the record. Specifically, per Medicare, CPT code J3490 has a status indicator of N. This means that cpt code J3490 is a packaged item and no additional payment is allowed. Based on this information, we decided that Medicare rules for coverage of the unclassified drug injection have not been met.Therefore, we decided that the Plan does not have to pay foran unclassified drug injection (J3490) provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on March 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 code 31500 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 31500 is intubation, endotracheal, emergency procedure. We find that CPT code 31500 is not supported in the medical record. Specifically, there is no documentation of an emergent endotrachel intubation for the date of service at issue. 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 services rendered on March 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the hearing aids purchased on January 19, 2020 from a non-participating provider. 
 
You asked the Plan to reimburse for the hearing aids. You say that you could not afford the plan hearing aid cost. The Plan denied your request. The Plan says you do not have out-of-network benefits. 
 
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 reimburse for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
Your EOC states, enrollees have a $500 allowance toward the cost of a medically necessary hearing aid, per ear, every three years when prescribed by a plan or plan designated provider and dispensed by a plan or plan designated vendor. 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 preapprove the item/service at issue. We found no exception that would require the Plan to reimburse for these items/services. Therefore, we decided that the Plan does not have to reimburse for the hearing aids purchased on January 19, 2020 from a non-participating provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on October 15, 2019.
You asked the Plan to pay for the hospital discharge day management. You say that your physician only provided medically necessary services to this enrollee in good faith. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist. You asked the Plan to pre-approve these services. You say that the provider is an expert in managing refractory uveitic patients. The Plan denied your request. The Plan says the services are available from network providers. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network ophthalmologist.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the gene panel provided on December 12, 2019.You asked the Plan to pay forgenetic testing. You say that this testing is approved by the Food and Drug Administration (FDA) and was medically necessary for the enrollee.The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this test is not FDA-approved and therefore is not covered.The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing testing is covered for tests that are FDA-approved and if the enrollee's cancer meets certain criteria.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 genetic testing. Our reviewer says that this testing meetsthe Medicare criteria for coverage. Our physician reviewer found the development of sophisticated genetic and molecular characterization of central nervous system (CNS) neoplasms has shown that histologically similar neoplasms can be characterized more accurately for prognosis and in some instances for response to different therapies. Molecular characterization of primary brain tumors/gliomas has had a substantial impact on stratification and eligibility in clinical trials for CNS neoplasms over the last 10 years and is increasingly becoming a common part of standard neuro-oncology management. Therefore, this service was medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan has to pay forTempus xT gene panel provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on May 6, 2019.
You asked the Plan to waive the copayment for the office visit. You submitted your bill for review. You say
that you need help with the bill. The Plan denied your request. The Plan says that the copayment 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 enrollees pay a $0 copayment for each Medicare-covered primary care doctor
visit.
The Plan says you must pay a $35 copayment for the office visit. Based on the Plan contract, however, you
cannot be asked to pay more than a $0 copayment for the office visit. The records show that the physician is an
internal medicine provider which is considered a primary care physician. Therefore, we decided that the Plan
has to waive the copayment for the office visit provided on May 6, 2019.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the partial colectomy (44140) to be provided by an out of network (OON) provider. You asked the Plan to pre-approve an OON colectomy. You say that this provider is more experienced than in-network providers. The Plan denied your request. The Plan says the requested service is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the partial colectomy (44140) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a robotic spinal fusion surgery/procedure (S2900,
22558, 61783).
You asked the Plan to pre-approve a robotic spinal fusion surgery/procedure. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria has not been met.
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 robotic spinal fusion
surgery/procedure. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found the medical literature does not support the need for
robotic spine fusion surgery over conventional surgery. More research is needed to show safety and efficacy of
robotic spine surgery.
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 robotic spinal fusion surgery/procedure have not been met. Therefore, we
decided that the Plan does not have to pre-approve a robotic spinal fusion surgery/procedure (S2900, 22558,
61783).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the unna boot strapping provided on December 4, 2019, December 11, 2019, December 18, 2019 and December 30, 2019.
You asked the Plan to waive the copayment for the unna boot strapping. You say that you are on a limited income. You say that you don't have the money to pay these bills. The Plan denied your request. The Plan says the copayments 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 $350 copayment for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a total of $553.68 for the unna boot strapping.

The unna boot strapping falls within the "Outpatient Surgery and Other Medical 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 the unna boot strapping provided on December 4, 2019, December 11, 2019, December 18, 2019 and December 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 2, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You submitted your bill for review. You say that you have no money to pay. 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 $175 copayment for Medicare-covered one-way ground ambulance benefit. You have been asked to pay a $175 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance Services" benefit category. The records show that you were transported by ambulance to the hospital. 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 ambulance transport provided on October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable oxygen concentrator purchased on July 18, 2019.You asked the Plan to pay forthe portableoxygen concentrator. You say that it is not right that you are being forced to pay for 2 units when you only need the portable unit.The Plan denied your request. The Plan says Medicare and the plan will only cover the rental of oxygen devices from approved suppliers and will not cover the cost of purchasing a portable oxygen concentrator.The Plan must follow Medicare rules. Medicare rules say that purchased oxygen equipment is statutorily non-covered.Therefore, we decided that the Plan does nothave to pay forthe portable oxygen concentrator purchased on July 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99285) provided on September 16, 2019.You asked the Plan to pay for[Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the billed service did not include an appropriate primary, first-listed or principal diagnosis.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 99285is not supported in the record. Specifically, this service was billed with a 'code first' diagnosis code. Per the ICD-10-CM, the underlying condition should be listed prior to this diagnosis code. Based on this information, we decided that Medicare rules for coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have not been met.Therefore, we decided that the Plan does not have to pay for the emergency department visit (99285) provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care (99225) provided on December 6, 2019 through December 7,2019.You asked the Plan to pay for the observation care. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says based on the rendering provider not being the provider that admitted the patient into observation, they should bill the appropriate outpatient service code.The Plan must follow Medicare rules. Medicare rules say that all other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the observation care have not been met. Specifically, the record indicates that the ordering physician on the date of the member's observation services began is not the rendering provider in this case. This provider should bill the appropriate outpatient service code.Therefore, we decided that the Plan does not have to pay for observation care (99225) provided on December 6, 2019 through December 7, 2019.