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

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on January 8, 2020.You asked the Plan to pay for the hospital outpatient clinic visit. 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 a hospital outpatient clinic visit provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on March 13, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because you have never been charged in the past. 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 $30 copayment per retail clinic visit. You have been asked to pay a $30 copayment for an office visit at a retail clinic. An office visit at a retail clinic falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on March 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 22, 2020.You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid order for this testing.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, we decided that the Plan does not have to pay for drug testing provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on March 22, 2019.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says maintenance therapy is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information we decided Medicare coverage criteria for the chiropractic services have not been met. Specifically, the documentation submitted does not include any medical records. Without medical records are unable to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for chiropractic services provided on March 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystoscopy provided on January 14, 2020.
You asked the Plan to reduce the copayment for the cystoscopy. You say that you were told by the hospital that you only had a $50 copayment. You say you should not be responsible for the additional charge of $125. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $175 copayment for each Medicare-covered visit to an outpatient hospital facility. You have been asked to pay a $175 copayment for the cystoscopy. The cystoscopy 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 reduce the copayment for the cystoscopy provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 25, 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 the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing visits.
You asked the Plan to pre-approve home health care. You say that you need a lot of care to help with your conditions. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
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 services. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you. The documentation does not indicate that you have ongoing skilled nursing needs that require an additional 5 visits. Without the need for skilled nursing or skilled therapy services, you do not meet the criteria for home health aide 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 home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request.The Plan says the enrollee does not meet criteria for coverage of an acute inpatient rehabilitation facility admission.The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a skilled nursing facility. In this case, a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period of time. The intensity of an inpatient rehabilitation facility admission is not warranted.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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan has to pre-approveinpatient admission requested on July 10, 2020.You asked the Plan to pre-approvethe inpatient admission. You say that the enrollee needs to be treated in the inpatient setting in the ICU.The Plan denied your request. The Plan says that the documentation shows that the enrollee can be treated in observation status.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 the inpatient admission. Our reviewer says that the documentation supports that the criteria for inpatient coverage are met in this case. Our physician reviewer found the enrollee presented to the ED around 1500 on July 9, 2020 after being found to have hyperkalemia in the PCP's office with altered mental status per his daughter. He was admitted to the ICU for acute renal failure. The review has determined that the record showed that at the time of the request for inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 inpatient admission have been met.Therefore, we decided that the Plan has to pre-approveinpatient admission requested on July 10, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistakeand/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 pay for the walking boot provided on December 30, 2019.
You asked the Plan to pay for the walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf (L4361). You say that the walking boot was medically necessary and the Plan should pay this claim. The Plan denied your request. The Plan says 0 units are allowed when the claim is submitted by a physician.
The Plan must follow Medicare rules. Medicare rules say that suppliers of DMEPOS must have its own unique Medicare identification number. In this case, the billing provider's reported NPI is not identified as a DME supplier and as such cannot bill for DME items under that NPI. Based on this information, we decided that Medicare rules for coverage of the walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf have not been met. Therefore, we decided that the Plan does not have to pay for the walking boot provided on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vertical bitewings - 7 to 8 radiographic images (D0277)
provided on February 3, 2020.
You asked the Plan to pay for the dental services. You say that you did research on the dental coverage that the
plan offers and the webpage did not list covered dental codes. You state that the website did not differentiate or
explain the different types of bitewing x-rays. The Plan denied your request. The Plan says the service is not a
covered benefit under the plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for vertical bitewings - 7 to 8
radiographic images (D0277) provided on February 3, 2020.
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 12, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were under the impression that this was a follow up from your surgery. You say that you normally don't get charged for that. 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 $35 copayment for Medicare-covered specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure. 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 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81120, 81121, 8117381235,
81272, 8127581310, 81311, 81314, 81321, 81404, 81405, and 81406 provided on March 10, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 81120, 81121, 81173, 81235, 81272, 8127581310, 81311, 8131481321, 81404, 81405,
and 81406 are not supported in the medical record. Specifically, the file shows that molecular
pathology genomic profiling for colon cancer was rendered. There was a more appropriate code to describe the
services provided. Based on this information, we decided that Medicare rules for coverage of the laboratory
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
coded 81120, 81121, 8117381235, 81272, 8127581310, 81311, 81314, 81321, 81404, 81405, and 81406
provided on March 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography (CT) scan of the head/brain rendered on July 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 70540 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 70450 and 70496. Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe computed tomography (CT) scan of the head/brain rendered on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services rendered from December 30, 2019 to January 3, 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 the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture services rendered from December 30, 2019 to January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 7, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were there for routine foot care not for diagnosis and medical or surgical treatment. You say that the $40 copayment should be removed. 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 non-routine Medicare-covered foot care visit. This is for diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs).
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Podiatry Services-Medicare covered" benefit category. The record show that you were treated for hammer toe, dry skin, left toe pain and a fungal infection 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 January 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 28, 2019 to October 27, 2019.You asked the Plan to pay for SNF care. You say that this should be covered by Medicare.The Plan denied your request. The Plan says the enrollee no longer needed skilled services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled nursing or skilled therapy services (or a combination of these services) on a daily basis beyond the last covered date. As a practical matter, this patient did not require the necessary services on an inpatient basis, in a skilled nursing facility setting beyond the last covered date. 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 pay for skilled nursing facility (SNF) care provided from September 28, 2019 to October 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the x-rays, EKG and back brace provided on January 15, 2020.
You asked the Plan to waive the deductible for the x-rays, EKG and back brace. You submitted your bill for review. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $198, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before the Pan will pay its share for your covered Medicare Part A and B services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" and "Durable Medical Equipment (DME) and related supplies" benefit categories. The Plan has followed Medicare rules by clearly disclosing in the contract that your $198 deductible applies to outpatient diagnostic tests and durable medical equipment. This cost sharing is a contractual obligation that had not been met at the time the x-rays, EKG and back brace were received on January 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the x-rays, EKG and back brace provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient rehabilitation services and injections provided by a chiropractic provider on December 3, 2019.
You asked the Plan to pay for rehabilitation services and injections. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services were not performed by a licensed therapy and are not covered by Medicare or the Plan when performed by a chiropractor.
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 services at issue are not manual manipulation of the spine. These services were performed by a chiropractor's office. Therefore, we decided that the Plan does not have to pay for outpatient rehabilitation services and injections provided by a chiropractic provider on December 3, 2019.