Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 23, 2019 through April 24, 2019.You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. Review of the file show that you received inpatient hospital care from April 23, 2019 through April 24, 2019. Your EOC states that enrollees must pay a $100 copayment for each inpatient stay. Therefore, you are asked to pay a $100 copayment for the inpatient hospital care. 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 inpatient hospital care from April 23, 2019 through April 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 17, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted does not include a physician order and lab results for presumptive drug testing.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 records provided 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 services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on April 17, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial hospital care provided on December 27, 2019.You asked the Plan to pay forthe initial hospital care. You say that hospice was revoked prior to the visit. You say that the claim should be reprocessed and paid.The Plandenied your request. The Plan says Original Medicare is responsible for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on December 25, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forthe initial hospital care provided on December 27, 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 LTACH care is medically necessary.The Plan denied your request. The Plan says 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 the enrollee is currently undergoing treatment at an acute hospital for gallstone pancreatitis and a non-obstructing kidney stone. The enrollee was transiently intubated and ventilated for surgery/procedures, but is no longer intubated or ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no reason to transfer the enrollee from the current 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe complete series of intraoral x-rays (D0210) provided on March 9, 2020.You asked the Plan to pay forthe complete series of intraoral x-rays. You say that your handbook says that radiographic x-rays are covered. You also say that you cannot afford to pay for this service.The Plan denied your request. The Plan says this service is not covered by your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe complete series of intraoral x-rays (D0210) provided on March 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99152 provided on January 3, 2020.
You asked the Plan to pay for CPT code 99152. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT
code 99152.
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 99152 is Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not
contain evidence that moderate sedation was performed with the presence of an independent trained observer.
Based on this information, we decided that Medicare rules for coverage of CPT code 99152 have not been met.
Therefore, we decided that the Plan does not have to pay for CPT code 99152 provided on January 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on September 26, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician.
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 the denied codes is: CPT 80307: Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service HCPCS G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found there were no claims submitted for an evaluation and management service. Review of claims history for this member, and a review of the submitted documentation did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. The review has determined that the records do not support the above denied codes. The records do not support an established relationship between the ordering physician and 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 services have not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on September 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on January 27, 2019.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that this was a follow-up procedure. You say that you would like this covered fully. 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 $300 copayment for outpatient surgery/in-network. You have been asked to pay a $300 copayment for a diagnostic colonoscopy. Since the colonoscopy was diagnostic in nature the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network 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 diagnostic colonoscopy provided by a participating provider on January 27, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the travel services provided on March 4, 2020.You asked the Plan to pay for the travel services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services received were not transplant related.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 pay for the travel services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found you had travel expenses for a Medical Doctor appointment made by your Transplant Center. This would be considered incident to or ancillary to transplant services since appointment was made by transplant center. The services received were indeed transplant related. Therefore, you meet criteria for coverage of these services.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 travel services have been met.Therefore, we decided that the Plan has to pay for the travel services provided on March 4, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown, core build-up, pontics and retainer crown provided on February 17, 2020.You asked the Plan to pay for the crown, core build-up, pontics and retainer crown. You say that you thought insurance would pay because this was an accident. You say that some of the bill should be paid.The Plan denied your request. The Plan says the services are not covered benefits.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, comprehensive dental services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the crown, core build-up, pontics and retainer crown provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided to the enrollee on August 29, 2019.You asked the Plan to pay for this testing. You say that this claim should be paid.The Plan denied your request. The Plan says the records provided do not support the services billed.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for drug testing provided to the enrollee on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 14, 2019.
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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, 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. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on August 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 4, 2020.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that both providers at the practice should be paid as in-network. The Plan denied your request. The Plan says out-of-network dental services are not covered benefits.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on March 4, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the outpatient surgery provided on January 7, 2020 and March 18, 2020.You asked the Plan to waive the copayment for the outpatient surgery. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says that they were unable to make a determination within the allotted time frame.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide a breakdown of how the claim was paid for in order to determine if the correct cost share has applied.Therefore, we decided that the Plan has to waive the copayment for the outpatient surgery provided on January 7, 2020 and March 18, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNurtec ODT tablets.You asked the Plan to pre-approveNurtec ODT tablets. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Nurtec ODT tablets are not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveNurtec ODT tablets.Benefits for Nurtec ODT tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on February 26, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the 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 fromout-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forlab work provided on February 26, 2020 by an out of network (OON) provider.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require IRF level of therapies and the enrollee's rehabilitation needs can be met at a lower intensity setting such as skilled nursing 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on January 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plandid not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forlab work provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies provided from February 21, 2020
through March 23, 2020 by a non-participating provider.
You asked the Plan to pay for incontinence supplies. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the record sent by your provider indicates that
these items are required due to incontinence.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided from
February 21, 2020 through March 23, 2020 by a non-participating provider.