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

We decided that the Plan does not have to waive the copayment for advanced imaging services provided on August 21, 2019.You asked the Plan to waive the copayment foradvanced imaging services. You say that you feel that once you are in the hospital, your insurance company should pay for everything.The Plan denied your request. The Plan says the correct copayment has been applied for the services that were provided.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$35 copayment for outpatient diagnostic tests/advanced imaging service. You have been asked to pay a $35 copayment for advanced imaging services. Advanced imaging services falls within the outpatient diagnostic tests/advanced imaging service 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 towaive the copayment foradvanced imaging services provided on August 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composites provided on September 11, 2019.
You asked the Plan to pay for the resin based composites. You say that these should be covered. The Plan
denied your request. The Plan says these 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin
based composites provided on September 11, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided on October 12, 2018.You asked the Plan to pay forambulance services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicarehealth 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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity.Therefore, we decided that the Plan has to pay forambulance services provided on October 12, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an insertion of interlaminar/interspinous process
stabilization/distraction device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary for this stage of disease
progression. The Plan denied your request. The Plan says this is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the
requested device is not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is considered experimental. More research is needed.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve an insertion of interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora surgical tray (A4550) provided on September 13, 2019.You asked the Plan to payfora surgical tray. You say that this was medically necessary.The Plan denied your request. The Plan says payment for this item is included in other services.The Plan must follow Medicare rules. Medicare rules say that payment for codes with astatus indicator of B is always bundled into payment for other services.We find that CPT code A4550 is not supported in the medical record. Specifically, this code has status indicator of B and is not separately payable. Based on this information, we decided that Medicare rules for coverage of a surgical tray have not been met.Therefore, we decided that the Plan does not have to pay fora surgical tray (A4550) provided on September 13, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on September 20, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99190 is not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay forthe special pump services rendered on September 20, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent nursing facility care provided on May 7, 2019.You asked the Plan to pay for the subsequent nursing facility care. You say that the enrollee was hospitalized with a hospitalist physician with the group and depends on the hospital staff to obtain the proper authorization for the enrollee's insurance plan. The Plan denied your request. The Plan says that there is no valid authorization for this service.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This facility is a contract providerwith the Plan. The file does not show that the Plan provided notice that the subsequent nursing facility care would not be coveredprior to the services being provided. Under Medicare rules, this means the subsequent nursing facility care is considered approved by the Plan. Therefore, we decided that the Plan has to pay forthesubsequent nursing facility care provided on May 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a spinal cord stimulator (63655 and
63685).
You asked the Plan to pre-approve the insertion of a spinal cord stimulator. You say that this is medically
necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for a spinal cord
stimulator.
The Plan follows Medicare rules. Medicare rules say that the insertion of a spinal cord stimulator is covered
only for enrollees who have undergone careful screening, evaluation and diagnosis by a multidisciplinary team
prior to implantation.
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 insertion of a spinal cord stimulator.
Our reviewer says that Medicare criteria for a spinal cord stimulator have not been met.
Our physician reviewer found the documentation does not support that the enrollee has undergone careful
screening, evaluation, and diagnosis by a multidisciplinary team which included psychological evaluation.
The documentation is insufficient to demonstrate that a spinal cord stimulator is medically reasonable and
necessary for the enrollee in this case.
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 insertion of a spinal cord stimulator have not been met. Therefore, we
decided that the Plan does not have to pre-approve the insertion of a spinal cord stimulator (63655 and 63685).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by the out of network provider.
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 services were rendered by a non-network provider without 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 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 July 18, 2019 by the out of network 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-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 rulesto determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 12/24/19 with atrial fibrillation with rapid ventricular rate (RVR) and congestive heart failure exacerbation. Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include frequent neurologic checks, surveillance laboratory studies, catheter care, close blood sugar control, and therapy services.The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are notavailable 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 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 carehospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on August 20, 2019.
You asked the Plan to waive the copayment for these services. You say that your visit was with a primary care physician and should have no copayment. The Plan denied your request. The Plan says the copayment was 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 $20 copayment per visit for outpatient hospital services.
Review of the file shows that you received outpatient hospital services on August 20, 2019. You have been asked to pay a $20 copayment for these services. These services fall within the outpatient hospital 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 the outpatient hospital services rendered to you on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for powered pressure-reducing air mattress (CPT Code E0277),
for the enrollee.
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. Low air loss mattresses are
considered medically necessary only for certain individuals who have pressure ulcers (bed sores) or skin grafts
located on their trunk or pelvis which meet certain criteria and have failed to improve over the past
month despite completing an ulcer treatment program. Therefore, we decided that the Plan does not have to pay
for powered pressure-reducing air mattress (CPT Code E0277), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 16, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that his was a medically necessary service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided on August 19, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain theproof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided on August 19, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on May 4, 2017 to July 2, 2017.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 with the required HIPPS code.The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with a HIPPS code.We looked at the file and Medicare rules. The claims were not billed with the required HIPPS code. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home health services rendered on May 4, 2017 to July 2, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 7, 2019 to October 26, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plandenied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 7, 2019 to October 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis provided on September 10, 2019.You asked the Plan to pay forthe prophylaxis. You say that the frequency is required to avoid periodontal services. You say that the claim should be paid.The Plan denied your request. The Plan says this service is only covered twice per plan year.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 plan also has a maximum benefit amount oftwo cleanings per plan year.The requested service is not covered because the Plan paid for thecleaningsprovided on January 8, 2019 and May 14, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay forthe prophylaxis provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a whole genome study.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee had a 300 panel genetic test on March 17, 2018.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the study. Our reviewer says that the requested study is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that coverage criteria have been met for the requested testing of the enrollee in this case. It has not been demonstrated that only the number of genes or testing that are reasonable and necessary to obtain necessary information for therapeutic decision making have been ordered, and that the enrollee has not previously received genetic testing for the disease/condition. 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 study have not been met. Therefore, we decided that the Plan does not have to pre-approve a whole genome study.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided on August 21, 2019.You asked the Plan to pay forthe emergency department services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says there is no separate reimbursement for CPT code 99053 whether the service is billed alone or with other procedures.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, we have confirmed that per the 2019 Physician Fee Schedule, code 99053 has a status code of B. This means that payment is bundled into another service. Based onthe claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forservices provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided on August 21, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from July 31,
2019 to October 19, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no
valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a
tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the
diabetic supplies provided to the enrollee from July 31, 2019 to October 19, 2019.