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

We decided that the Plan does not have to pay for physician's services provided on November 12, 2019, November 18, 2019 and November 26, 2019.
You asked the Plan to pay for the physician's services. You say that due to the urgency of your medical condition, you could not find a provider that would accept your plan and the appointments offered to you were greater than a month. You say you were able to see this cardiologist who has been your doctor for more than 30 years. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the physician's services. 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 physician's services provided on November 12, 2019, November 18, 2019 and November 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora SNF stay provided from November 12, 2019 to December 8, 2019.You asked the Plan to waive the copayment fora SNF stay. You say that you cannot afford 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 Planclearly says that enrollees must pay a $0 copayment per day for days 1-20 and a $160 copayment per day for days 21-100 for SNF care. The enrollee had a SNF stay from November 12, 2019 to December 8, 2019. The enrollee is not being charged a copayment for days 1-20 (November 12, 2019 to December 1, 2019). The enrollee is responsible to pay a $160 (copayment) for days 21-26 (December 2, 2019 to December 7, 2019). $160 (copayment) x 6 (SNF days) = $960. The enrollee has been asked to pay the total copayment amount of $960 for a SNF stay. A SNF stay falls within the SNF 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 fora SNF stay provided from November 12, 2019 to December 8, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 19, 2019 by an out of network (OON) provider. You asked the Plan to pay for laboratory tests. You say that these tests were an extension of the enrollee's visit with the ordering provider. 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 provider 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 December 19, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for infections following a recent stroke. The enrollee has a tracheotomy following the stroke, but is not on a ventilator. There appear to be no plans for decannulation. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator provided on February 12,
2019 to April 12, 2019 by an out of network provider.
You asked the Plan to pay for automatic external defibrillator (AED) garment (K0606). You say that the AED
garment was medically necessary. The Plan denied your request. The Plan says you did not request prior
authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We
found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does
not have to pay for the automatic external defibrillator provided on February 12, 2019 to April 12, 2019 by an
out of network provider.
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 January 3, 2020 to January 31, 2020.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 claim was not billed with a supporting type of bill.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.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 an invalid Type of Bill code for home health services.Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 3, 2020 to January 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.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 the enrollee is currently undergoing treatment at an acute care hospital (ACH), having initially been admitted with weakness. The enrollee subsequently developed respiratory and renal failure. The enrollee was intubated/ventilated and later received a tracheotomy. The enrollee is no longer on a ventilator. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiac device evaluations provided from October 8, 2019 through March 4, 2020.
You asked the Plan to waive the copayment for the cardiac device evaluations. You say that you shouldn't have to pay a copayment each time the doctor reviews the recordings. You say that you cannot afford to pay this each month. 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 $45 copayment for other Medicare-covered outpatient diagnostic tests from an in-network specialty provider. You have been asked to pay a total of $188.01 for the cardiac device evaluations.
Date of Service
Service
Standard Copayment
Member Liability
October 8, 2019
Cardiac Device Evaluation
$45
$45
November 26,2019
Cardiac Device Evaluation
$45
$37.68
December 3, 2019
Cardiac Device Evaluation
$45
$29.97
February 3, 2020
Cardiac Device Evaluation
$45
$37.68
March 4, 2020
Cardiac Device Evaluation
$45
$37.68
TOTAL:
$188.01
The cardiac device evaluations 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 for the cardiac device evaluations provided from October 8, 2019 through March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing test provided on March 10,
2020.
You asked the Plan to waive the copayment for the hearing test. You say that you paid $40 at the time of the
visit but were also billed an additional amount. The Plan denied your request. The Plan says the copayment
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40
specialist office visit copayment for each Medicare-covered diagnostic hearing exam.
You have been asked to pay a $40 copayment for the hearing test. The hearing test falls within the "Hearing
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 the hearing test provided
on March 10, 2020.
Please note, this case is only for the $40 copayment for the hearing test. Contact the Plan directly with
questions regarding other services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nebulizer with compressor provided on January 2, 2020 by an out of network provider.You asked the Plan to pay for the nebulizer with compressor. You say that the nebulizer with compressor was medically necessary.The Plan denied your request. The Plan says you did not have prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay for the nebulizer with compressor provided on January 2, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 8, 2020. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified. 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 documentation of the ordering physician's intent that the tests be performed. 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 for the drug testing services provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider, for a basic lymphedema pump.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this pump is available in the plan's 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 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 a referral to an out-of-network provider, for a basic lymphedema pump.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that LTACH care is necessary to optimize the enrollee's care. The Plan denied your request. The Plan says the enrollee is receiving appropriate 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 pay for 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 the patient is currently undergoing treatment at an acute care hospital (ACH) for coronary artery disease and progressive renal failure. The enrollee has been started on hemodialysis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 pay for long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 25, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 95861 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 95861 is needle electromyography; 2 extremities with or without related paraspinal areas.We find that CPT code 95861 is not supported in the medical record. Specifically, there is no documetnation of needle electromyography to two extremities. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan doesnot have to pay forthe testing services rendered on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 19, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says services from non-participating providers are not covered unless pre-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 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 physician's services provided on November 19, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on January 13, 2020.
You asked the Plan to pay for genetic test. You say that this test is covered by Medicare and the enrollee met the criteria for testing. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test was not medically necessary.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this service is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on October 23, 2019.
You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not a Medicare benefit for the diagnoses listed and were performed for screening services.
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 tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 12, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure codes 80157 and 80177 are 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 80157 is assay of carbamazepine; free. The definition of
code 80177 is levetiracetam drug screen.
We find that CPT codes 80157 and 80177 are not supported in the medical record. Specifically, there is no
documentation of testing of carbamazepine to support code 80157 or of a levetiracetam drug screen to support
code 80177. 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 laboratory services rendered on
February 12, 2020