Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient physician services provided on October 29, 2019.
You asked the Plan to pay for the inpatient physician service. You say that this should be excepted from authorization requirements since this was referred by a network provider. This should be covered under plan directed care. The Plan denied your request. The Plan says that payment for this code was included in payment for other services by this provider on the same date. The plan was not able to review its original denial rationale within the required time frame.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial rationale is that payment for this claim was included in payment made for another claim from the same provider. However, the Plan failed to provide evidence that payment was made to this or any other provider on a different claim for this date of service. Without this documentation, we find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the inpatient physician services provided on October 29, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehab facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator management with tracheostomy care, hemodialysis, telemetry monitoring, surveillance laboratory studies, tube feeding, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prolapse surgery with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is not part of your network of providers, and the requested services can be provided by an in-network provider.
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 prolapse surgery with an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 13, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you have never been charged in the past and were not given a choice as to where to receive the blood work. 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 $40 copayment for lab services provided in an outpatient hospital facility. You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall 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 copayment for laboratory services provided on February 13, 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 records provided show that IRF care is needed due to the enrollee's severe visual impairment. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have 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 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 enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy, but the documentation does not support that his functional level requires an intensive rehabilitation therapy program provided in an IRF. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision (76377) provided on February 28, 2020 by the appealing provider. You asked the Plan to pay for3D rendering with interpretation and reporting. You say that the services were provided and payment should be rendered.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 pay for 3D rendering with interpretation and reporting. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the CMS rules state that the necessity for 3D rendering must be mentioned in order to fulfill the second criterion, medical necessity. In other words, a statement in the report must be made as to the reason the 3D rendering was necessary in addition to the usual 2D examination. This was not mentioned in the report.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D rendering with interpretation and reporting have not been met.Therefore, we decided that the Plan does not have to pay for3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post processing under concurrent supervision (76377) provided on February 28, 2020 by the appealing provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle orthosis (L1971) provided January 16, 2020.
You asked the Plan to pay for the orthosis. You say that please see the attached medical records which prove the medical necessity of the item and process the claim for payment. The Plan denied your request. The Plan says the billed supply code cannot be verified as the documentation submitted did not indicate the provider discussed the need for the billed supply code.
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 pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a physical examination of the ankles and
feet. The documentation does not support that the enrollee has weakness or deformity of the feet and ankles, and requires stabilization for medical reasons, and has the potential to benefit functionally. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for ankle orthosis (L1971) provided January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 19, 2020.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says that you must use a network provider to have these services covered.
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. The Plan covers dental services when you are treated by a contracted dental provider. We looked at the file and Medicare rules. You did not receive these services from a contracted dental provider. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided from December 18, 2019 to February 18, 2020.
You asked the Plan to waive the coinsurance for DME. You say that you could not use the device because it was faulty. 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 20% coinsurance for DME and related supplies. You received DME on December 18, 2019. The allowed mount is $3,044.48 and 20% of that is $608.90. You received DME on January 18, 2019. The allowed mount is $3,044.48 and 20% of that is $608.90. You received DME on February 18, 2019. The allowed mount is $3,044.48 and 20% of that is $608.90. The total amount you owe is: $1,826.70. You have been asked to pay the total coinsurance amount of $1,826.70 for DME. DME falls within the DME and related 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 DME provided from December 18, 2019 to February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on January 28, 2020.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you had a similar injection that didn't cost $300. You say that the change in cost should be reconsidered. 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 $300 copayment for all other services. You have been asked to pay a $300 copayment for the arthrocentesis. The arthrocentesis 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 the arthrocentesis provided on January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix (J1447).
You asked the Plan to pre-approve Granix. You say that this is necessary due to the enrollee's white blood cell count. The Plan denied your request. The Plan says this use of the medication is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Granix. Our reviewer says that the criteria for coverage of Granix have not been met. Our physician reviewer found the enrollee has a diagnosis of neutropenia related to cytomegaloviraus and renal transplant. The major drug compendia, authoritative medical literature and accepted standards of medical practice do not support Granix for this diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix (J1447).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 6, 2020 to January 15, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the discharge was delayed and the enrollee should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day for days 1-8 for inpatient hospital care. The enrollee had an inpatient hospital stay from January 6, 2020 to January 15, 2020. Therefore, the enrollee is responsible to pay the $225 copayment for days 1-8 (January 6, 2020 to January 13, 2020). $225 (copayment) x 8 (inpatient days) = $1,800. The enrollee has been asked to pay the total copayment amount of $1,800 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 6, 2020 to January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on March 5, 2020.
You asked the Plan to pay for genetic tests. You say that you performed tests that were ordered by the referring provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered by Medicare for screening purposes.
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. Without this information, you have not demonstrated that these tests were ordered for Medicare-covered purposes. Based on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral-periapical x-ray (D0220) provided on
January 30, 2020.
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 exceeds the allowable frequency for the calendar year.
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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of this service have not been met. Specifically, the Plan contract allows for coverage of only one
intraoral x-ray per calendar year. Two intraoral x-rays were provided on this date of service, in which one procedure was paid for by the Plan. Therefore, we decided that the Plan does not have to pay for the additional intraoral-periapical x-ray (D0220) provided on January 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 20, 2020.
You asked the Plan to pay for the laboratory 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an Addiction Treatment Center. 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 provided on January 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81201, 81276, 81275, 81404 provided on October 23, 2019.
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 81201, 81276, 81275, 81404 are not supported in the medical record. Specifically, these services were not performed by you, the biller. Pass-through billing is not permitted. 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 81201, 81276, 81275, 81404 provided on October 23, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee after June 27, 2020.You asked the Plan to pre-approveSNF care. You say that the enrollee has been experiencing pain since his fall.The Plan denied your request. The Plan says that that the enrollee can receive the care he needs at home.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before June 27, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.Therefore, we decided that the Plan has to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee after June 27, 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 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.