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

We decided that the Plan does not have to waive the copayment for tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion provided on June 10, 2020, at the outpatient department of the facility.
You asked the Plan to waive the copayment for the services. You say that you thought the place of service was at a doctor's office and were unaware that a simple procedure would be classified as a surgery with a $100 copayment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion provided on June 10, 2020, at the outpatient department of the facility. You are asked to pay a $100 copayment for the services. Your EOC states that enrollees must pay a $100 copayment for Medicare-covered surgery or other services at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.
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 tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion provided on June 10, 2020, at the outpatient department of the facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 20, 2020 by a non-participating provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-participating 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 referring provider 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 forthe laboratory services provided on July 20, 2020 by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan has to hold you harmless forservices provided on May 26, 2020.You asked the Plan to hold you harmless forthe services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says that this provider needs to become site certified and you are not responsible for 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 willnot be covered. The Plan follows these rules.You were referred for the services by a contract provider. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan.Therefore, we decided that the Plan has to hold you harmless forservices provided on May 26, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
April 8, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician
services provided to the enrollee on April 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe SNF services. You say that you need the physical therapy to be able to go home.The Plan denied your request. The Plan says that there are in network providers available.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-approvethe skilled nursing facility (SNF) services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is 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 requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forradiopharmaceutical therapy (79005) provided on June 18, 2020.You asked the Plan to pay forthe radiopharmaceutical therapy. You say that you would like reconsideration becuase this claim denied as a duplicate in error.The Plan denied your request. The Plan says the submitted documentation supports one unit of 79005-26, which was previously approved/paid.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiopharmaceutical therapy have not been met. Specifically, the record only shows that one unit of radiopharmaceutical therapy was rendered. This service was previously processed and paid.Therefore, we decided that the Plan does not have to pay forradiopharmaceutical therapy (79005) provided on June 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is 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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the documentation does not support that the enrollee's nursing, medical and
rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation
care. The documentation does not support that the enrollee in this case requires at least 3 hours a day /5 days a
week, or 15 hours over 7 consecutive days, of therapy services. There is a reasonable expectation that this
enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. However, the IRF is not necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided on August 7, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-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 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 forlab services provided on August 7, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pay forx-ray of the chest (CPT 71045) provided to the enrollee on July 30, 2020.You asked the Planto pay forthe x-ray. You say that this should be paid for.The Plandenied your request. The PlansaysthatCPT 71045 is not supported as being rendered by the denied provider.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 71045 is "radiologic examination, chest; single view."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 x-ray. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found the report of the single view chestx-ray Accession # 8472176 was compared to a prior 2 view chest x-ray same date. Thus, the report supports the contention there were 2 separate chest x-ray exams on the same date, 7/30/20. Based upon this information the interpretation for the single view chest x-ray rendered by the provider on 7/30/20, accession # 8472176 should be reimbursed.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 x-ray have been met.Therefore, we decided that the Planhas to pay forx-ray of the chest (CPT 71045) provided to the enrollee on July 30, 2020.If the Plandoes not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora cataract removal (66984), anesthesia for an eye procedure (00142), and an intraocular lens (V2632) received on July 7, 2020.You asked the Plan to waive the copayment forcataract surgery and related supplies. You say that the provider's office told you that your entire cataract surgery would be covered and you would not have anything to pay.The Plan denied your request. The Plan says the correct copayment was applied.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 $335 copayment for surgery services at an outpatient hospital. You have been asked to pay a $335 copayment for cataractsurgery and related supplies. Cataract surgery and related supplies fallwithin the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora cataract removal (66984), anesthesia for an eye procedure(00142),and an intraocular lens (V2632) received on July 7, 2020.Your complaint about receiving erroneous or misleading information about your cost-sharing responsibility from the provideris not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
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 these services are medically necessary.The Plan denied your request. The Plan says that the criteria for acute rehab was not met as skilled nursing or home physical/occupation therapy visits were more appropriate.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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Thecomplexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for pneumonia and rib pain after a fall. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapyor occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePBRT (CPT Code 77525).You asked the Plan to pre-approvePBRT. You say that the member has a rising prostate-specific antigen level and a T1c N0 M0 prostate cancer on biopsy. Radiation treatment has been recommended for this condition.The Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the standard of care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial.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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Our physician reviewer states the services are unfavorable as they do not believe the LCD criteria are met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met.Therefore, we decided that the Plan does not have to pre-approvePBRT (CPT Code 77525)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223).
You asked the Plan to pre-approve deep sedation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered under Medicare or the Plan.
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 of Medicare coverage, the requested deep sedation with dental codes D9222 and D9223 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (81407, 81408 and 80479) provided on June 25, 2020.

You asked the Plan to pay for the cardiovascular risk assessment testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels except that basic lipid panel.

The Plan must follow Medicare rules. Medicare rules say that policy denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment testing have not been met. Specifically, the record indicates that the services billed were not for a basic lipid panel. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (81407, 81408 and 80479) provided on June 25, 2020.