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

We decided that the Plan does not have to pre-approve SNF admission and services for the enrollee.You asked the Plan to pre-approve SNF services. You say that the enrollee is not able to care for herself.The Plan denied your request. The Plan says continued daily intensity with no expectation of change is not necessary or appropriate.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 services. Our physician reviewer found that the enrollee's current level of function is supervision with feeding and grooming, maximal assist/dependent with transfers, toileting, and lower body dressing, supervision with upper body dressing, and standing with moderate to maximal assist. There are no noted daily skilled complex nursing needs. While she may benefit from continuing speech, physical, and occupational therapy, the records do not support the need for continued daily therapy.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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies haven't proven that this procedure is helpful for treatment of this health problem.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is indicated for L4/5 and L5/S1anterior lumbar interbody fusion with posterior decompression and fusion fixation L4-S1. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the request for bone marrow aspiration for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the approved lumbar spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspiration is not medically reasonable and necessary for the approved lumbar fusion.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-approve bone marrow aspiration for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by out of network provider. You asked the Plan to pay for genetic tests. You say that the enrollee's treating provider ordered this test to obtain medically necessary information.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed (CPT Code 77387) provided to the enrollee on July 8, 2019.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Medicare guidance says status code "I = Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services."Therefore, we decided that the Plan does not have to pay for guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed (CPT Code 77387) provided to the enrollee on July 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentforthe MRI provided on July 8, 2019 and July 17, 2019.You asked the Plan to waive the copayment forthe MRI's. You say that you were informed they couldn't do them at the same time. You say that you were only charged $150 by the provider.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 $300 copayment for outpatient diagnostic tests. Covered tests include computed tomography, magnetic resonance angiogram, magnetic resonance imaging and positron emission tomography. You have been asked to pay $223.09 for the MRI provided on July 8, 2019 and $250.19 for the MRI provided on July 17, 2019, which are less than the standard $300 copayment. The total amount you owe is $473.28 ($223.09 + $250.19 = $473.28).The MRI's fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe MRI provided on July 8, 2019 and July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on December 8, 2018.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 99239 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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 hospital discharge services rendered on December 8, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from December 23, 2018 to December 25, 2018.You asked the Plan to pay foracute inpatient hospital care. You say that the treating physician decided to admit this enrollee out of concern that the enrollee's symptomswere attributed to an escalating clinical condition, and you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because inpatient hospital care was not medically necessaryand the enrollee could have been treated at a lower level of care.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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on themedical records provided, at the time of inpatient admission it was not reasonably expected that the enrollee's necessary hospital care(including earlier emergency department or observation care) would span at least 2 midnights. Care at a lower level of care would have been appropriate.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that thePlan does not have to pay forthe acute inpatient hospital care provided from December 23, 2018 to December 25, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forvaccine services received on January 3, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis is not a covered benefit.In the absence of injuryor direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services.Therefore, we decided that the Plandoes not haveto pay forvaccine services received on January 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ophthalmological medical examination and evaluation providedon August 2, 2019.You asked the Plan to waive the copayment forthe ophthalmological medical examination and evaluation. You say that you thought there would be a zero copayment for this service.The Plan denied your request. The Plan says the copayment applied appropriately per the Evidence of Coverage.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'scontract with the Plan clearly says that enrollees must pay $40 copayment for vision care, Medicare-covered vision services. The enrollee has been asked to pay $40 copayment for the ophthalmological medical examination and evaluation. The ophthalmological medical examination and evaluation falls within the vision care, Medicare-coveredvision services benefit category. This means that the enrolleehas been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation that the enrolleeagreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran ophthalmological medical examination and evaluation provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraoral x-ray(D0210) provided on August 6, 2019.You asked the Plan to pay forthe intraoral x-ray. You say that you told the office you would only do what is covered. You say that you were not informed you would be charged for the non-covered service.The Plan denied your request. The Plan says this service can only be done once every 3 years.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 ofMedicare coverage, the Plan also has a maximum benefit of one intraoral x-ray every 36 months. The Plan paid for an intraoral x-rayon March 6, 2018, which exhausted your benefit.Therefore, we decided that the Plan does not have to pay forthe intraoral x-ray (D0210) provided on August 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forelectroencephalograph (EEG) tests provided by "the doctor" from February 18, 2019 to June 19, 2019.You asked the Plan to waive the copayment forEEG tests. You say that these single tests done over 72 hours, so each should be one copayment.The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.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 copayment for each EEG test performed by a specialist physician. Each EEG test is performed in a 24-hour testing period, therefore 72 hours of testing would include 3 separate tests for each separate date of service. 6 tests were performed, resulting in a total copayment obligation of $120.You have been asked to pay $20 copayment for each EEG test. EEG tests fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forelectroencephalograph (EEG) tests provided by"the doctor" from February 18, 2019 to June 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on July 3, 2019.You asked the Plan to pay for these services. You say that the physician provided the needed service in good faith and the patient received excellent medical care.The Plan denied your request. The Plan says the member did not meet inpatient hospitalization criteria but did meet observational level of care criteria. 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 pay for these services. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the member was admitted for an inpatient hospital stay for chest pain. The member has an extensive medical history most significant to coronary artery disease (statuspost CABG, two vessel bypass in 2013), paroxysmal atrial fibrillation (non-compliant with anticoagulant), Congestive Heart Failure, Hypertension, Hyperlipidemia, COPD and GERD. Upon presentation to the Emergency Room, her vital signs were within normal limits. The member had no cough, no sputum, no adventitious sounds to lung fields, and no shortness of breath. The member denied any nausea, vomiting, diarrhea or constipation or any abdominal pain.A review of systems was unremarkable for any other systems. She was admitted for observation to the telemetry unit. Her condition stabilized and improved and she was discharged home on July 4, 2019 with outpatient follow-up. 
The review has determined that the record did not show that at the time of 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 these services have not been met.We decided that code 99223 was inappropriately billed; therefore, the Plan does not have to pay for the initial hospital care (99223) provided on July 3, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe sigmoidoscopy and endoscopy provided on July 30, 2019.You asked the Plan to waive the copayment forthe sigmoidoscopy and endoscopy. You say that you were not informed of a copayment.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 Medicare-covered services in a hospital outpatient facility.You have been asked to pay a $300 copayment for the sigmoidoscopy and endoscopy. The sigmoidoscopy and endoscopyfallwithin 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 forthe sigmoidoscopy and endoscopy provided on July 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe spine x-ray provided on August 21, 2019.You asked the Plan to waive the copayment forthe spine x-ray. You say that you have never paid a copayment for an x-ray in the past.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 $30 copayment for Medicare-covered x-rays. You have been asked to pay a $30 copayment for the spine x-ray. The spine x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe spine x-ray provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam rendered to you on June 12, 2019.
You asked the Plan to waive the copayment for these services. You say that the provider didn't collect the copayment at the time of services and said that the services were covered. The Plan denied your request. The Plan says the copayment was 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 eye exams to treat diseases and conditions of the eye.
Review of the file shows that you received an eye exam on June 12, 2019. You have been asked to pay a $35 copayment for these services. These services fall within the Medicare-covered eye exams to treat diseases and conditions of the eye benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The Plan has not denied coverage of these services. 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 eye exam rendered to you on June 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bilateral lower eyelid revision, and forehead surgery provided on August 23, 2019 by the outof network provider.You asked the Plan to pay forthe surgical services. You say that you initially received the services in February 2019. You say that the procedure did not go well and had to have additional surgeries that did not improve the outcome. You say that you went to another office. You say that they could not perform a revision and recommended you a provider in Atlanta. You say you did not physically see this provider until the day before the procedure was scheduled and therefore were not able to obtain an authorization. You also say that you did not believe that you needed another authorization as the services had been previously authorized in February.The Plan denied your request. The Plan says authorization was not obtained before you received the services on August 23, 2019. The Plan says the services can be provided 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has confirmed there are networkproviders 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 forthe bilateral lower eyelid revision, and forehead surgery provided on August 23, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forsubsequent observation care provided February 22, 2019 to February 23, 2019.You asked the Plan to pay forsubsequent observation care. You say that this is not a duplicate service and the correct place of service was billed.The Plan denied your request. The Plan says this service was billed incorrectly with an outpatient place of service and the service date falls between the admission and discharge date of an inpatient confinement.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 99226 is subsequent observation care.We find that CPT code 99226 is not supported in the medical record. Specifically, when a patient is in a registered inpatient status, all services billed by all providers should reflect and acknowledge the patient's inpatient status. Basedon this information, we decided that Medicare rules for coverage of subsequent observation care have not been met.Therefore, we decided that the Plan does not have to pay forsubsequent observation care provided on February 22, 2019 toFebruary 23, 2019.