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

We decided that the Plan does not have to pay for the ECG provided on November 10, 2019.
You asked the Plan to pay for the ECG. You say that lab tests were performed, and per regulations the reports
are supposed to be furnished within 24 hours which does not allow you to have ample time to verify eligibility
and process authorization beforehand. You also say that the tests were performed by your lab in good faith. The
Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers
all hospice care from the effective date of election to the date of discharge or revocation. During the election,
fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness
starting on the date of the hospice election until the first day of the month following the month in which
hospice is revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ECG provided on November 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the foot x-ray provided on January 23, 2020.
You asked the Plan to waive the copayment for the foot x-ray. You say that you were informed you couldn't get the x-ray without a referral. You say that they are trying to charge you $35. The Plan denied your request. The Plan says 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 clearly says that you must pay a $50 copayment for each Medicare-covered x-ray in an in-network outpatient hospital facility. You have been asked to pay a $50 copayment for the foot x-ray. The foot x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the foot x-ray was completed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the foot x-ray provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services. 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 for an office visit provided on October 30, 2019 by an out of network (OON) provider.
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 is receiving necessary services in an acute care hospital and is at an
appropriate level of care. The acute care hospital is able to provide all of the services the enrollee requires.
Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as
an inpatient rehabilitation facility, a skilled nursing facility or a sub-acute 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for circulating tumor cell (CTC) assay testing provided on June 24, 2019.
You asked the Plan to pay for CTC assay tests. You say that you are requesting payment for this claim. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that circulating tumor cell (CTC) assays were not covered by Medicare for date of service June 24, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTC assay tests have not been met. Therefore, we decided that the Plan does not have to pay for circulating tumor cell (CTC) assay testing provided on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon January 13, 2020.You asked the Plan to pay for the physician's 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 servicesat 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 payfor physician's services provided on January 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for OncoCee Target Select Circulating Tumor Assay provided on October 8, 2019.
You asked the Plan to pay for OncoCee testing. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that circulating tumor cell assays such as OncoCee Target Select Circulating Tumor Assay are non-covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OncoCee testing have not been met. Therefore, we decided that the Plan does not have to pay for OncoCee Target Select Circulating Tumor Assay provided on October 8, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on September 30, 2019.
You asked the Plan to pay for an electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says without a physician's interpretation, note, and signature, computer-generated electrocardiogram reports don't meet the requirements for the professional component of an electrocardiogram.
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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We asked our coder 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 electrocardiogram. Our reviewer says that CPT code 93010 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include a complete, written report similar to that which would be prepared by a specialist in the field, therefore this service is not separately reimbursable. Rather, payment is bundled in the emergency room visit of 99285-Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function, which was also performed by the same physician on the same date of service, by the same group/practice and the health plan paid for service 99285.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on September 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
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 that you are medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician or a need for acute rehabilitation nursing care. You may benefit from further physical and occupational therapy but do not require an intensive therapy program. An IRF admission is not medically necessary based on your current functional status and medical stability. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns for tooth #'s 28, 29, and 31 and a pontic for tooth #30. You asked the Plan to pre-approve the retainer crowns and pontic. You say that the enrollee has only one posterior tooth missing on the left side that would not be included in a removable partial. You also say that the missing bicuspid on the lower left would not be included in a partial because there has been shifting of the teeth and not enough room for a pontic or partial tooth. The Plan denied your request. The Plan says the documentation fails to indicate any specific needs or conditions that preclude the use of a removable prosthesis. 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. The Plan covers the retainer crowns and pontic when the services are medically necessary and reasonable. 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 retainer crowns and pontic. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is adequate room on the opposing side of the arch for clasping even without replacing a tooth on the left side. The missing tooth on the left side of the arch makes for a easy area to clasp a framework. Our reviewer found that tooth #30 would be replaced on a partial denture and clasp the adjacent teeth which have adequate bone support. Our physician reviewer also found that as the space left by the missing tooth #30 can be filled with a partial denture, the Plan criteria does not allow for a finding of medical necessity for the requested bridge from tooth #'s 28 to 31. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the retainer crowns and pontic have not been met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns for tooth #'s 28, 29, and 31 and a pontic for tooth #30.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 physician services provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on January 29, 2020.
You asked the Plan to pay for a chiropractic office visit. You say that this should be covered. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99202) provided on January 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the respiratory assistance device provided on December 29, 2019. You asked the Plan to waive the coinsurance for the respiratory assistance device. You say that the insurance is paying nearly three times the cost of the device which makes your coinsurance more. 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 20% coinsurance for Medicare-covered benefits. You have been asked to pay $53.95 which is 20% of the allowed amount for the respiratory assistance device. The allowed amount is $269.74. ($269.74 x 20% = $53.95). The respiratory assistance device falls within the "Durable Medical Equipment (DME) and Related 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 for the respiratory assistance device provided on December 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Synvisc (J7325) injections provided February 10 to February 20, 2020.
You asked the Plan to waive the coinsurance for the Synvisc injections. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 20% coinsurance for Part B drugs. You have been asked to pay a 20% coinsurance for the Synvisc injections. The Synvisc injections falls within the Part B 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 Synvisc (J7325) injections provided February 10 to February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided January 20, 2020.You asked the Plan to pay for the chest x-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim is a duplicate.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 71045 is not supported in the medical record. Specifically, two claims were submitted for chest x-rays on the same service date. The record does not substantiate that two x-rays were performed. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71045) provided January 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D7140, D3428) provided November 14, 2019 to December 2, 2019.You asked the Plan to pay for the dental services. You say that the services should be covered.The Plan denied your request. The Plan says dental services provided out-of-network are not a covered benefit.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 items or services are not among those covered under this benefit. Dental services rendered by out-of-network providers are excluded from coverage.Therefore, we decided that the Plan does not have to pay for dental services (D7140, D3428) provided November 14, 2019 to December 2, 2019.
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 the enrollee needs these services to be as independent as possible before returning home. The Plan denied your request. The Plan says the enrollee's needs can be met in another setting.
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 generally medically stable with debility and hypoxia with no recent neurological or orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient physician three times per week or need for acute rehab nursing care. Currently the patient is requiring assist for mobility and ADLs. While the patient may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy three hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on February 7, 2020.You asked the Plan to waive the copayment forthe colonoscopy. You say that you should not have to pay the copayment because you knew you did not need the colonoscopy. 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 $325 copayment for surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows the colonoscopy was performed due to occult blood in stools which makes the colonoscopy diagnostic in nature.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 forthe colonoscopy provided on February 7, 2020.