Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest and abdomen.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the information should contain a current clinical evaluation that includes the results of laboratory studies, results of plain x-rays, and/or an ultrasound relevant to the requested procedure.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the details of the left ureteral injury in the past requiring stent placement are unknown to this reviewer. However, the patient presents with left lower quadrant pain and investigation is indicated in light of the prior ureteral injury and stent removal. The concern would be left ureteral stricture, injury etc. CT of the abdomen and pelvis would be the procedure of choice to analyze both the urinary tract and the left sided bowel. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest and abdomen.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 8, 2019 to June 9, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not necessitate skilled services during this time as clinically the enrollee's condition no longer required daily skilled services at an inpatient SNF level of 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 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 for the skilled nursing services provided from June 8, 2019 to June 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 12, 2019 to September 13, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was too sick to be discharged.The Plan denied your request. The Plan says inpatient admission was not necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 12, 2019 to September 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on December 10, 2019.You asked the Plan to pay for the hearing aids. You say that friends had told you that this provider was the least expensive and you wanted to save yourself some money. You were also told by a plan representative that you can go to this provider.The Plan denied your request. The Plan says the hearing services are covered when the  services are received from a in network provider.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when the services are rendered by a in network provider. We looked the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met.Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foran ultrasound and dual-energy X-Ray absorptiometry (DXA) test provided from May 28, 2019 to June 3, 2019.You asked the Plan to waive the coinsurance for ultrasound and DXA test. You say that you did not know that this provider was not in-network.The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.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 40% coinsurance for out-of-network ultrasound and DXA test. The allowed amounts of these tests total $177.11, resulting in a coinsurance obligation of $70.85.You have been asked to pay 40% coinsurance for ultrasound and DXA test. Ultrasound and DXA test 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 coinsurance foran ultrasound and dual-energy X-Ray absorptiometry (DXA) test provided from May 28, 2019 to June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit you had on December 16, 2019.
You asked the Plan to pay for the visit. You say that you didn't have a wellness visit in 2018, so you had two in 2019. The Plan denied your request. The Plan says this is only covered once per year.
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 $0 copayment for an annual wellness visit once every 12 months. Review of the file shows that you had an annual wellness visit on December 16, 2019. The records also show that you had a covered annual wellness visit on January 4, 2019. This type of visit is only covered once every 12 months. Since the plan already paid for one wellness visit for 2019, the requested visit exceeds the benefit limit and is not covered. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the annual wellness visit you had on December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 26, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met. The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on November 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 19, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on December 17, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that you thought it was an
urgent care center. The Plan denied your request. The Plan says the correct copayment 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 $120
copayment for emergency care.
You have been asked to pay a $120 copayment for an emergency room visit. Since an emergency room visit
was provided, the correct copayment has been applied. An emergency room visit falls within the emergency
care 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 an emergency room visit
provided by a participating provider on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that you are seeking an unbiased opinion. The Plan denied your request. The Plan says there are providers available in your 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided 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 digital analysis of electroencephalogram (EEG) services coded 95957 provided on July 14, 2019.
You asked the Plan to pay for the digital analysis of electroencephalogram (EEG) services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). We find that CPT code 95957 is not supported in the medical record. Specifically, it is not appropriate to report 95957 for source localization when there are no spikes to analyze. The submitted medical records indicate that "no spikes were detected". Based on this information, we decided that Medicare rules for coverage of the digital analysis of electroencephalogram (EEG) services have not been met. Therefore, we decided that the Plan does not have to pay for the digital analysis of electroencephalogram (EEG) services coded 95957 provided on July 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) provided on December 16, 2019.
You asked the Plan to pay for the back brace. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the back brace have not been met. Specifically, the record shows that the Plan requested progress notes indicating the need for the billed service. There is insufficient documentation to verify the supply billed. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on December 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visits provided from August 18, 2019 to August 21, 2019.
You asked the Plan to waive the copayments for the emergency room visits. You say that you do not believe you should be responsible for the copayments because you were told you would not be charged the next visits for the shots. 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 $90 copayment for up to a maximum for emergency care. You have been asked to pay a $90 copayment for each of the emergency room visits. The emergency room visits fall within the "Emergency care" 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 emergency room visits provided from August 18, 2019 to August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on February 14, 2020.

You asked the Plan to waive the copayment for urgent care visit. You say that you paid $35 like the provider asked and were told that is what you would owe. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $50 copayment for urgent care visit. 

You have been asked to pay $50 copayment for urgent care visit. Urgent care visit falls within the Urgently Needed 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 an urgent care visit provided on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 13, 2019 by an out of network (OON) provider. You asked the Plan to pay for laboratory testing. You say that you had no reason to believe that the tests ordered would be deemed not medically reasonable and necessary. 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 November 13, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a pain injection (CPT 64483 and 64484).You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says that there is a lack of signs and symptoms of nerve compression on exam and magnetic resonance imaging.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 injection. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found by the utilization criteria, you have one more epidural steroid injection within this 12 month period. You have had 5 epidural injections in the period starting 5/28/19. You had the final three starting 9/11/19. The request is medically reasonable and 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 the injection have been met.Therefore, we decided that the Plan has to pre-approve a pain injection (CPT 64483 and 64484).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 to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an office visit (CPT 99213), an electrocardiogram, routine (ECG), (CPT 93000) and programming device evaluation (CPT 93285) provided on October 17, 2019.
You asked the Plan to pay for the physician's services. You say that you received authorization from the Plan for services to be provided by this physician. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the referring physician are not network providers with the Plan. The Plan did not pre-approve the CPT codes for these services rendered. 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 for an office visit (CPT 99213), an electrocardiogram, routine (ECG), (CPT 93000) and programming device evaluation (CPT 93285) provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 24, 2019 to October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for home consultation. You say that you are appealing.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 insufficient records were submitted to the Plan to make a clinical determination.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 forthe medical services provided on October 24, 2019 to October 29, 2019 by an out of network (OON) provider.