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

We decided that the Plan does not have to waive the copayment forthe epidural injection provided on August 12, 2019.You asked the Plan to waive thecopayment forthe epidural injection. You say that you expected the copayment to be $30. You say that you were not informed there would be a $400 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 $400 copayment forin-network,Medicare-covered outpatient hospital surgery services.You have been asked to pay a $400 copayment for the epidural injection. The epidural injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The epidural injection is considered a surgical procedure that was provided by the hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractualobligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe epidural injection provided on August 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesacroiliac (SI) joint fusion surgery.You asked the Plan to pre-approveSI joint fusion surgery. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this surgery is not medically necessary.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 SI joint fusion surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a sacroiliac (SI) joint instability, fracture, or lesion. SI joint fusion surgery for degenerative back pain remains experimental.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint fusion surgery have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac (SI) joint fusion surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the laboratory services provided on May
21, 2019 and September 3, 2019.
You asked the Plan to waive the copayments for the laboratory services. You say that you have not had to pay a
lab fee for the lipid panel if it was related to your physical. 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 $20
copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR
testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are
performed.
You have been asked to pay a $20 copayment for the laboratory services on each date of service. The
laboratory services 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 copayments for the laboratory services provided on May 21,
2019 and September 3, 2019.
Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 13, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 13, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 12, 2018 to September 7, 2018.You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claims are being submitted with inappropriate home health data to process and pay claims.The Plan must follow Medicare rules. The rules say that anyclaim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim includes inappropriate and missing data. The HHRG code on the claims indicates there were Non-Routine Supplies (NRS) provided, but are not submitted on the claim. Additionally, the claims were submitted without the required Qcode. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 12, 2018 to September 7, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper GI endoscopy provided on September 23, 2019.
You asked the Plan to waive the copayment for the upper GI endoscopy. You say that you were never advised there would be a copayment for this service. You say you cannot afford to pay this amount because you are on a fixed income. 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 $225 copayment for freestanding Ambulatory Surgical Center. You have been asked to pay a $225 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical center" 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 upper GI endoscopy provided on September 23, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 19, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was strictly a preventive service and should be covered as such. 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 $300 copayment for freestanding Ambulatory Surgical Center. You have been asked to pay a $300 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the colonoscopy was performed because of abdominal pain and an abnormal CT scan of the gastrointestinal tract. Therefore, the colonoscopy is considered diagnostic in nature.
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 colonoscopy provided on October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of network
provider on October 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services
rendered by non-participating providers in non-participating facilities require prior authorization as outlined in
the enrollee's EOC.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider
on October 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you are a reference laboratory and do not have information on the enrollee's insurance requirements or limitations. 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 September 10, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on July 12, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was received after the timely filing limit.
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 services was not filed until August 27, 2019. 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 services provided on July 12, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery.
You asked the Plan to pre-approve bariatric surgery. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35; (2) at least one co-morbidity related to obesity; and (3) been unsuccessful with medical treatment for obesity. We looked at the file and Medicare rules. The most recent medical record provided is a progress note from November 11, 2019, which shows that your BMI is 30.98. For coverage of bariatric surgery, your BMI must be greater than or equal to 35. Based on this information, we decided that Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve bariatric surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation rendered to you on October 16, 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 services are not covered 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 service at issue is not manual manipulation of the spine. The file shows that the provider submitted a claim for procedure code 97014 (electrical stimulation therapy). Therefore, we decided that the Plan does not have to pay for the electrical stimulation rendered to you on October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee needs to regain maximal function.The Plan denied your request. The Plan says the services are not medically necessary.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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 2, 2020 with chronic obstructive pulmonary disease (COPD) exacerbation, hypoxemia, and acute bronchitis. As of March 8, 2020 she needs assistance from two with ambulating 90 feet. She needs assistance with basic activities of daily living. She is generally medically stable and does not require an acute hospital inpatientstay with an interdisciplinary approach to rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for the nursing facility care (99309). You say that the services rendered were medically necessary and provided in good faith.The Plan denied your request. The Plan says there is no valid referral for this service.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/servicesat 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 November 4, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care and initial nursing facility care provided from March 18, 2019 to March 21, 2019 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care and initial nursing facility care. You say that this provider could not deny any medical services that were essential for the enrollee's health treatment. You also say that your provider depends upon the hospital staff to verify eligibility and to obtain the proper authorization for in-network and out-of-network providers from the enrollee's insurance. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that there was no authorization on file.
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 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 subsequent nursing facility care and initial nursing facility care provided from March 18, 2019 to March 21, 2019 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mobility scooter.You asked the Plan to pre-approve a mobility scooter (K0899). You say that you want to go to zoos and parks and be able to fold a scooter into the trunk of a car and take on an airplane.The Plan denied your request. The Plan says this type of PMD is not approved/accredited by Medicare.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that your condition can be improved by a walker. The file does not show you can safely operate the PMD being requested. There is no home assessment, and neither Medicare nor the Plan cover PMDs for use only outside the home.This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve a mobility scooter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance transport provided on September 30, 2019.
You asked the Plan to waive the deductible for the ambulance transport. You say that you should not be penalized for using an out of network service. The Plan denied your request. The Plan says that the claim processed 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 there is a $500 deductible for ambulance services. The item or service you asked the Plan to waive the deductible for falls within the covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on September 30, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance transport provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on April 15, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment.Therefore, we decided that the Plan does not have to pay foran ankle-foot orthosis (L1971)provided to the enrollee on April 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test services provided on May 16, 2019 by an OON provider.
You asked the Plan to pay for the drug test services. You say that you were not aware of the requirement of obtaining a prior authorization for this enrollee's plan type at the time of rendering services. You also say that you provided the services in good faith and believed them to be medically necessary. The Plan denied your request. The Plan says the services were ordered by an out-of-network provider and provided by an out-of-network laboratory. The Plan also says that the services were not prior authorized.
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 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 drug test services provided on May 16, 2019 by an OON provider.