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

We decided that the Plan does not have to waive the copayment for the bladder catheterization procedure you had at an outpatient hospital facility on February 17, 2021.
You asked the Plan to waive the copayment for the bladder catheterization procedure. You say that you are on a fixed income and cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $100 copayment for outpatient procedures and services at an outpatient hospital facility. You have been asked to pay a $100 copayment for the bladder catheterization procedure. The bladder catheterization procedure falls within the outpatient procedures and services at an outpatient hospital facility
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 bladder catheterization procedure you had at an outpatient hospital facility on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided on December 17, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291, 81328, 81355, 81401, 81479) provided on December 17, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the doctor prescribed additional physical therapy to prevent further functional decline before surgery. You say that the enrollee has met criteria for medical necessity for restarting therapy and you are appealing the denial. The Plan denied your request. The Plan says additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 10 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the patient has had prior therapy and is compliant in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on February 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that there are in-network providers available for these services.
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 had network providers available who could have provided 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 a specialist office visit provided on February 23, 2021 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87481, 87653, 87640, 87798) provided on March 18, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you are an independent laboratory and do not receive any member information until after the services are rendered. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 records provided for review also show that the enrollee was referred by a non-participating provider. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 laboratory services (87481, 87653, 87640, 87798) provided on March 18, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on January 12, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an outpatient surgery. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

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 had network providers available who could have provided 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 an outpatient surgery provided on January 12, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on November 4,
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 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 hospital discharge services. 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 November 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic sequencing localization, initial procedure, (88365) provided on February 26, 2021.

You asked the Plan to pay for the laboratory service. You say that the date of services is for the date that the stain is read. You also say that the service still falls under the original surgery date of February 11, 2020.

The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the genetic sequencing localization, initial procedure, (88365) provided on February 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved and you are no longer a threat to yourself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital services. It is not expected you would improve in a reasonable period of time as you are not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. You were cooperative and compliant with medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81185, 81401, 81403, 81404, 81405, 81406, 81439, 81479) provided on September 21, 2020.

You asked the Plan to pay for laboratory services. You say that this testing should be covered. The Plan denied your request. The Plan says this was reported with an incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81185, 81401, 81403, 81404, 81405, 81406, 81439, 81479) provided on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI scan of the brain (70551) provided on June 11, 2019.

You asked the Plan to pay for an MRI of the brain. You say that the claim was originally filed in a timely manner. The Plan denied your request. The Plan says rules for payment have not been met because the claim for the services at issue was filed later than one calendar year after the date of service.

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 an MRI of the brain was not filed until March 29, 2021. 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 an MRI scan of the brain (70551) provided on June 11, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (Upper GI endoscopy) and colonoscopy with polyp removal you had on March 29, 2021.

You asked the Plan to waive the copayment for the upper GI endoscopy and colonoscopy. You say that this was a screening service that should be covered at $0 copayment. The Plan denied your request. The Plan says this was a diagnostic surgical service, so 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 $325 copayment for surgical services in an outpatient hospital facility. 

Records show that on this date of service, you had both an Upper GI endoscopy and a colonoscopy with polyp removal. You have been asked to pay a $325 copayment for the upper GI endoscopy and colonoscopy. Records also show that the colonoscopy was billed as a diagnostic, not screening, service due to your medical conditions and medical history. Regardless of whether the colonoscopy is a screening procedure or not, the upper GI endoscopy you had is always considered a surgical service, which is why the surgery copayment applies here. 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 esophagogastroduodenoscopy (Upper GI endoscopy) and colonoscopy with polyp removal you had on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) mechanical traction (97012) outpatient office visit (99213) provided April 16, 2021 to April 28, 2021.

You asked the Plan to pay for the chiropractic services. You say that you get relieve from having your spine stretched at and feel that this treatment should be allowed and covered by the chiropractic office. The Plan denied your request. The Plan says these services are not covered when rendered 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. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) mechanical traction (97012) outpatient office visit (99213) provided April 16, 2021 to April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with an orthopedic surgeon on April 28, 2021.

You asked the Plan to waive the copayment for the orthopedic surgery visit. You say that you only saw the doctor for five minutes and he advised you that he was leaving the medical group and referred you to another doctor. The Plan denied your request. The Plan says you were charged this copayment 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 copayment for visits with a specialist. 

You have been asked to pay a $40 copayment for the orthopedic surgery visit. The orthopedic surgery visit falls within the visits with a specialist benefit category. This copayment applies regardless of the reason for the visit. 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 visit you had with an orthopedic surgeon on April 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee has no strength to live on his own, and the doctor has recommended SNF. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for end-stage renal disease (ESRD) services provided to the
enrollee on February 28, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the services were not urgent or emergent, or approved in advance.

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 had network providers
available who could have provided 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 end-stage renal disease (ESRD) services provided
to the enrollee on February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and lab work provided on September 24, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services and lab work. You say that you would like this claim reprocessed and paid. You say that these services were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services.

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 had network providers available who could have provided 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 physician services and lab work provided on September 24, 2020 by an out-of-network (OON) provider.