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

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on November 5, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you need some help with this bill. The Plan denied your request. The Plan says the correct copayment has been 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 $300 copayment for outpatient surgery/outpatient hospital/outpatient surgery service. You have been asked to pay a $300 copayment for an outpatient surgery. An outpatient surgery falls within the outpatient surgery/outpatient hospital/outpatient surgery 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 copayment for an outpatient surgery provided by a participating provider on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each (CPT Code 86316).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the information sent in does not show medical necessity. The Plan states the requested testing may be used to assist in the evaluation of the enrollee's disease and medical records submitted were reviewed and most of the information was other test results. The Plan states there is no documentation explaining how the requested test will significantly change the treatment or management of the enrollee's disease and the provider must show medical need before this request can be approved.
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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there is no documentation explaining how the requested test will significantly change the treatment or management of the enrollee's disease. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each (CPT Code 86316).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNFcare.You asked the Plan to pre-approveSNF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay 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 above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveSNF care.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the Emergency Department visit provided on February 5,
2020.
You asked the Plan to pay for the Emergency Department visit at an Independent Freestanding Emergency
Department. You say that the provider is balance billing you. The Plan denied your request. The Plan says
Medicare does not cover services that are not performed by a Medicare certified provider.
The Plan must follow Medicare rules. The rules say no provider or supplier shall receive payment for services
furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. The
facility is a non-Medicare approved/certified freestanding emergency facility. The CMS policy to allow
licensed IFEDs to temporarily provide care was not in effect until April 20, 2020. Therefore, we decided that
the Plan does not have to pay for the Emergency Department visit provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Corus CAD testing provided on May 8, 2020.You asked the Plan to pay forthe Corus CAD testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 Corus CAD testing 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 forthe Corus CAD testing provided on May 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic eye exam (92004) performed
on November 12, 2018.
You asked the Plan to waive the copayment for a diagnostic eye exam. You say that your appointment was for
the annual exam and you were told there would be no copayment for the visit. The Plan denied your request.
The Plan says the correct copayment 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 $40
copayment for an exam to diagnose and treat diseases and conditions of the eye.
You have been asked to pay a $40 copayment for a diagnostic eye exam. The case record shows that your eye
exam on November 12, 2018, resulted in a medical diagnosis. A diagnostic eye exam is distinct from a routine
eye exam. A diagnostic eye exam falls within the "Vision care" 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 diagnostic eye exam (92004) performed on November 12, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression device E0651 and segmental
pneumatic appliance (E0667).
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you have attached
all the supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says this
service did not meet the Medicare criteria and is not covered.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
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 pneumatic compression device and
appliance. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the available clinical documentation in the case file does
not support that a pneumatic compression device and segmental pneumatic appliance are medically reasonable
and necessary for the enrollee in this case. There is insufficient documentation of symptoms, objective
measurements that establish the severity of the enrollee's condition, and response to therapeutic intervention.
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 pneumatic compression device and appliance have not been met. Therefore,
we decided that the Plan does not have to pay for pneumatic compression device E0651 and segmental
pneumatic appliance (E0667).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe CardioMEMS device (CPT Codes: C2624 and 33289).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are considered experimental and investigational.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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this circumstance, therapy change based on data obtained from a CardioMEMSdevice has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according toleading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare coverage criteria are not met,  since the device should still be considered experimental or investigational.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 pre-approvethe CardioMEMS device (CPT Codes: C2624 and 33289).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approvethe Prolia. You say that you would like reconsideration because this drug is medically necessary.The Plandenied your request. The Plan says the member does not meet step therapy exception criteria.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia. Our reviewer says that a trial of oral biphosphonate and zoledronic acid is required before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on February
18, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says review of the medical records submitted shows this was a hospital to hospital transport.
The medical records show the enrollee had weakness, distal portions of arms and legs. The gross motor skills
remained intact. The enrollee could move her arms and legs equally and was able to use fingers to sign her
name. The enrollee had intact sensation to upper and lower extremities but reported feeling weak in hands and
feet. There were no other signs of neurological impairment, speech was normal, and face was symmetrical. The
closest facility with neurologic services would have been 65-minutes by ground, and 31-minutes by air.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your
medical condition is such that transportation by ground ambulance is not appropriate. Based on the medical
records provided, there is no indication that the enrollee was unable to travel by ground ambulance or that her
condition was such that time was of the essence for treatment from one facility to the other. Medicare rules for
coverage of this service have not been met.
Therefore, we decided that the Plan does not have to pay for air ambulance services provided to the enrollee on
February 18, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the ophthalmologist medical exam and reduce the copayment for the imaging services from $39.65 to $20. We decided that the Plan does not have to waive the copayment for the imaging service.
You asked the Plan to waive the copayment for the ophthalmologist medical exam. You say that the Plan issued a copayment waiver for July 1 through December 31, 2020. The Plan says that the correct copayments have been applied.
We decided that the Plan has to waive the copayment for the ophthalmologist medical exam and reduce the copayment amount for the imaging services from $39.65 to $20.
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 must pay a $20 copayment for outpatient diagnostic tests and therapeutic services and supplies. In addition, the Plan issued a copayment waiver for in-person appointments with your primary care provider (PCP) or any specialist between July 1 and December 31, 2020. The Plan says you must pay $40 in total copayments for the ophthalmologist medical exam ($0.35 copayment) and the imaging service ($39.65). Based on the Plan contract, however, you cannot be asked to pay more than $20 for imaging services. In addition, the Plan agreed to waive the copayment for specialist visits between July 1 and December 31, 2020. Therefore, we decided that the Plan has to waive the copayment for the ophthalmologist medical exam (92014) and reduce the copayment for the imaging service (92133) from $39.65 to $20.
We also decided that the Plan does not have to waive the copayment for the imaging service.
Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests and therapeutic services and supplies. The copayment waiver issued by the Plan specifically states that the waiver does not include any charges that may be associated with labs, X-rays, or other tests that the provider may order as part of your visit. Therefore, we decided that the Plan does not have to waive the copayment for the imaging service received July 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82550, 86803, 83880, 86832, 86833 and 85025 provided on June 26, 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 payable.
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 82550, 86803, 83880, 86832, 86833 and 85025 are not supported in the medical record. Specifically, Medicare Guidance says when the hospital obtains laboratory tests for outpatients under arrangements with clinical laboratories or other hospital laboratories, only the hospital can bill for the arranged services. Manual and automated laboratory services submitted with a CMS facility POS 19, 21, 22, 23, 26, 34, 51, 52, 55, 56, 57 or 61 will not be reimbursable. These services are reimbursable to the facility. When facilities obtain manual or automated laboratory tests for patients under arrangements with an Independent Laboratory, Reference Laboratory or pathology group, only the facility may be reimbursed for the services. 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 82550, 86803, 83880, 86832, 86833 and 85025 provided on June 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from
January 20, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 mental health care. Our
reviewer says that Our physician reviewer found the health plan's denial of continued inpatient psychiatric
services is appropriate. You did not appear to require inpatient mental health treatment beyond the date in
question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations
while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date
in question. It did not appear that the services were reasonably expected to improve your condition or for the
purpose of diagnosis beyond the date in question. Our physician reviewer was unable to find an individualized
treatment plan however the entire chart is not present. It did appear that the records were supervised and
evaluated by a physician. Based upon review the records provided for the admission, you do not meet the
criteria for continued acute inpatient mental health treatment for the dates in question of January 20, 2021,
forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or
visual hallucinations and was cooperative/compliant with treatment while not showing any threats the safety.
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 mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care from January 20, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care (99222) provided on September 8, 2019.You asked the Plan to pay forthe initial hospital care. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says this claim was not received within twelvemonths or onecalendar year from the date when theservices were rendered.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the initial hospital care was not filed until October 6, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe initial hospital care (99222) provided on September 8, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient care provided from June 27, 2020, to June 29, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the inpatient care was not medically necessary.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 requested inpatient care was not medically reasonable andnecessary. Our physician reviewer found that by 7:16 p.m. on June 27, 2020, the enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility because her acute abdominal pain was assessed, and no acute pathologies were found. She remained hemodynamically stable, with no acute lab abnormalities and she did not exhibit a decline in her status. Diagnostics revealed no acute pathologies and she did not meet SIRS criteria. The post-stabilization care services at the non-Plan facility from 7:16pm on June 27, 2020, to June 29, 2020, were not medically reasonable or necessary. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.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 forthe inpatient care provided from June 27, 2020, to June 29, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on 
February 5, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not payable as the claim was 
submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was not filed until September 9, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the psychiatric diagnostic evaluation (90792) provided on February 5, 2019.