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

We decided that the Plan does not have to pay for CPT code 36005 provided on March 6, 2020.
You asked the Plan to pay for CPT code 36005. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says modifier's -LT and -RT should be used whenever a procedure is performed on only one side. The file shows that this procedure was only performed on the right side and an appropriate modifier was not billed with CPT code 36005 in this case. Based on this information, we decided that Medicare rules for coverage of CPT code 36005 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 36005 provided on March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B prescription drugs provided on January 16, 2020.
You asked the Plan to waive the coinsurance for Medicare Part B prescription drugs. You say that you disagree with the charges because you feel that they are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on January 16, 2020. The total allowed amount is $5,117.64 and 20% of that is $1,023.53. You have been asked to pay the total coinsurance amount of $1,023.53 for Medicare Part B prescription drugs. Medicare Part B prescription drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B prescription drugs provided on January 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Computed Tomography (CT) scan of the brain (70450) provided April 11, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that the copayment should be waived. 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 $250 copayment for Diagnostic Radiology. You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the Diagnostic Radiology 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 a Computed Tomography (CT) scan of the brain (70450) provided April 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Positron Emission Tomography (PET) scan (78815) provided February 11 to February 12, 2020.
You asked the Plan to waive the copayment for the PET scan. You say that the copayment should be waived. 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 $240 copayment for Advanced Imaging. You have been asked to pay a $240 copayment for the PET scan. The PET scan falls within the Advanced Imaging 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 a Positron Emission Tomography (PET) scan (78815) provided February 11 to February 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora bone scan (78306) provided March 14, 2020.You asked the Plan to waive the copayment forthe bone scan. You say that the copaymentis a hardship and should be waived.The Plan denied your request. The Plan says the correct copayment was applied per the plan contract.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 Diagnostic Radiology. You have been asked to pay a $325 copayment for the bone scan. The bone scan falls within the Diagnostic Radiology 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 bone scan (78306) provided March 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Magnetic Resonance Imaging (MRI) of
the brain (70553) provided February 18, 2020.
You asked the Plan to waive the coinsurance for the MRI. You say that the coinsurance should be waived. The
Plan denied your request. The Plan says the correct cost-sharing has been 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 40%
coinsurance for out-of-network diagnostic radiology.
You have been asked to pay a 40% coinsurance for the MRI. The MRI falls within the out-of-network
diagnostic radiology 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 coinsurance for Magnetic
Resonance Imaging (MRI) of the brain (70553) provided February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider for physical therapy.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe plan has network providers for the needed 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 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 Plandoes not haveto pre-approvea referral to an out-of-network provider for physical therapy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from October 1, 2019 to October 6, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the enrollee was admitted to receive skilled Physical Therapy and Occupational therapy services in order to return to her prior level of function and return toher home. You also say that the enrollee continued to make progress with the continued delivery of Physical and Occupational therapy.The Plan denied your request. The Plan says Medicare Part A coverage criteria was not met for a SNF stay for these dates of service. The Plan also says that the enrollee could have been safely discharged home on October 1, 2019.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from October 1, 2019 to October 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services coded as D0120, D1110, D0274, D0220, D0230, D4342, D4381, D2954, D2740 and D2393 provided February 17, 2020 to March 10, 2020.
You asked the Plan to pay for the dental services. You say that you disagree with the provider's billing and is hoping someone would be able to help you understand this billing. The Plan denied your request. The Plan says services rendered prior to eligibility with the Plan are not covered. The benefit maximum has been exhausted.
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. Services rendered on February 17, 2020 were rendered prior to the effective date under the Platinum Dental Rider. Services not listed under the Description of Benefits is not covered. The benefit maximum is $1,000. The plan paid $164 and $836, therefore the annual maximum has been exhausted. After the annual maximum is exhausted, any remaining charges are your responsibility. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services coded as D0120, D1110, D0274, D0220, D0230, D4342, D4381, D2954, D2740 and D2393 provided February 17, 2020 to March 10, 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 you are not able to do things by yourself. The Plan
denied your request. The Plan says you do not need to be seen by a rehab physician 3 times a week, or need an
intensive team for care.
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 physician reviewer found
that you presented to the acute hospital with a fall that resulted in a pelvic fracture. You were treated nonsurgically.
You are walking using a rolling walker with minimum assistance. You require minimum to
moderate assist for transfers and activities of daily living. You are medically stable. The complexity of your
nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy
services, but you do not require an intensive inpatient rehabilitation therapy program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an inpatient rehabilitation facility.
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on September 13, 2019 by an out of network (OON) provider.You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 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 outpatient services provided on September 13, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.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 you do not require services at the proposed LTACH that are not already available at the current acute care hospital.Medicare coverage criteria for transfer to an LTACH are not 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the requested admission 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 enrollee is able to walk 40 feet with a rolling walker. The enrollee required moderate assistance for transfers. The enrollee required contact guard assistance to minimum assistance for activities of daily living. The documentation does not support that the enrollee requires an interdisciplinary approach to rehabilitation care. The documentation does support that the enrollee requires physical therapy and occupational therapy, but does not support that the enrollee requires an an intensive inpatient rehabilitation therapy program. The enrollee's care needs can be met at a lower level of 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services required are called custodial care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 8, 2019
You asked the Plan to pay for the physician's services. You say that the services were medically necessary. The Plan denied your request. The Plan says out-of-network services require 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 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 March 8, 2019
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 transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 you do not require services at the proposed LTACH that are not already available at the current acute care hospital. Less than an additional 25 days of acute care is estimated to be needed based on the provided documentation. There are no services available at the proposed LTACH that are not available and covered at the current facility. Completion of the course of care at the current setting (surgery, treatment of infection, ventilation weaning) can be appropriately completed at the current facility. Medicare coverage criteria for transfer are not 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 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.