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

We decided that the Plan does not have to pay for the medical services provided on January 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that you disagree with the denial of payment. 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 January 8, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you were at a restaurant waiting to be seated when your blood sugar levels dropped. You say that your friend called 911 and after the paramedics arrived they began an IV to get your blood sugar levels back up. You stated that the paramedics told you that you were in a semi-coma. You say that the call was for urgently needed medical care. After your blood sugar levels got back up, the paramedics told you that they would transport you to a nearby hospital. You say that you declined transportation because you did not want the added expense of a hospital bill and you opted to eat as soon as possible instead. You asked the Plan to reconsider their denial because the services were urgently needed.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
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 a LTACH admission is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted and treated in the current acute care hospital for respiratory failure which required intubation, tracheostomy, and PEG tube placement. Pneumonia was diagnosed and treated with antibiotics and encephalopathywas also diagnosed. Gradual improvement has beennoted during the prolonged hospital stay. The enrolleewas able to be weaned off sedation and pressors, but ventilation support isstill required. According to the records, the enrolleedoesnot require services at the LTACH that would be required for more than 25 days, based on the current recovery rate as documented in the records. There are no services available at the proposed LTACH that the enrollee requiresthat are not already available at the current acute care facility. Therefore, the proposed LTACH transfer is not justified and will be considered not medically necessary for the current condition of the enrollee.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient facility services provided on November 23, 2019.You asked the Plan to pay for the outpatient facility services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient facility services provided on November 23, 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 a long term acute care hospital admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of a LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 11, 2018 to September 25, 2018.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford the second $1,500 charge. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $375 copayment per day for days 1-4 for inpatient hospital care. The enrollee had an inpatient hospital stay from September 11, 2018 to September 25, 2018. Therefore, the enrollee is responsible to pay a $375 copayment for days 1-4 (September 11, 2018 to September 14, 2018). $375 (copayment) x 4 (inpatient days) = $1,500. The enrollee has been asked to pay the total copayment amount of $1,500 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from September 11, 2018 to September 25, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the stent placement and laboratory test provided on May 23, 2019 and July 18, 2019.
You asked the Plan to waive the cost share for the stent placement and laboratory test. You say that it will be extremely difficult to pay the charges. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a $7 copayment for Medicare-covered lab services. You have been asked to pay a total of $3,851.94 for the stent placement and laboratory test.
Date of Service
Service
Allowed Amount
Standard Cost
Member Liability
May 23, 2019
Stent Placement
$12,075.81
20%
$2,322.27
May 23, 2019
Laboratory Test
$15.48
$7
$7
July 18, 2019
Stent Placement
$12,075.81
20%
$1,515.67
July 18, 2019
Laboratory Test
$15.48
$7
$7
TOTAL:
$3,851.94
The stent placements fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The laboratory tests 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 cost share for the stent placement and laboratory test provided on May 23, 2019 and July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cataract surgery provided on January 22, 2020.
You asked the Plan to waive the copayment for a cataract surgery. You say that you disagree with the charges. 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 a $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $275 copayment for a cataract surgery. A cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 cataract surgery provided on January 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device.
You asked the Plan to provide a pneumatic compression device (E0652). You say that the enrollee needs a pneumatic compression device and appliances. The Plan denied your request. The Plan says there is no documentation of a 4 week trial with a standard pump or measurements of truncal swelling.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 or detailed measurements of the truncal swelling. Therefore, we decided that the Plan does not have to provide a pneumatic compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on November 8, 2019.You asked the Plan to pay for discharge day management. You say that this should be covered.The Plan denied your request. The Plan says this is not supported by the records.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, the submitted medical records do not document the time spent on this service, so this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met.Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided on November 8, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for the outpatient clinic visit provided on January 15,
2020.
You asked the Plan to waive the copayment for the outpatient clinic visit. You say that the Plan has been
approving payment for years. You say that the cost should be approved. The Plan denied your request. The
Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan does not say in clear and accurate terms
how much you should expect to pay for a non-surgical visit to an outpatient hospital.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay the
observation copayment for an outpatient clinic visit. The Plan contract does not clearly say how much enrollees
must pay for a non-surgical visit in an outpatient hospital. This means that the Plan did not follow Medicare
rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the
copayment for the outpatient clinic visit provided on January 15, 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 to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing.You asked the Plan to pre-approve the comprehensive BRCA 1 and 2 testing. You say that the requested services are needed to determine whether the enrollee has ovarian cancer and for treatment planning.The Plan denied your request. The Plan says there is no documented personal history of cancer.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that BRCA testing is covered and considered medically necessary for certain medical indications. 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 comprehensive BRCA 1 and 2 testing. Our reviewer says that comprehensive BRCA 1 and 2 testing is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee has a personal history of breast, ovarian, pancreatic or prostate cancer. Therefore, the requested genetic testing is not shown to be medically necessary or reasonable.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 comprehensive BRCA 1 and 2 testing have not been met.Therefore, we decided that the Plan does not have to pre-approve comprehensive BRCA 1 and 2 testing.
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 the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 transfer to a short-term acute care hospital for evaluation and treatment of the immediate acute medical condition would be the most appropriate disposition for the enrollee at this time. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a rehab shower commode chair with wheels (E1399).
You asked the Plan to pay for a shower commode chair. You say that this item is being requested for the comfort of the family member/caretaker since it would be much easier to move the enrollee from the bed to rehab shower commode chair and be transported to the bathroom. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a rehab shower commode chair with wheels (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on October 8, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says medical records from the ordering provider were not submitted.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The recordsprovided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forthe lab services provided on October 8, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on November 19, 2019.
You asked the Plan to pay for the train of four testing. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code. IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95999) provided on November 19, 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 a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee was admitted and treated in the current acute care hospital for a stage IV sacral decubitus ulcer with cellulitis. She was treated with debridement, IV antibiotics, and other basic wound care during the stay. Blood cultures were negative and there was no evidence of ongoing osteomyelitis. According to the records, the enrollee does not require services at the LTACH such as daily physician visits, long-term IV antibiotic treatments, and daily complex wound care which would be required for more than 25 days. There are no services available at the proposed LTACH that the enrollee requires that are not already available at the current acute care facility. Therefore, the proposed LTACH transfer is not justified and will be considered not medically necessary for the current condition of the enrollee. 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.