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

We decided that the Plan does not have to waive the coinsurance for the electrophysiological evaluation, the intra-cardiac echocardiogram, and the stimulation pacing heart provided on October 8, 2019.
You asked the Plan to waive the coinsurance for the electrophysiological evaluation, the intra-cardiac echocardiogram and the stimulation pacing heart. You say that you were not expecting an additional coinsurance. You say you were quoted a $325 copayment and now you are getting a bill for a coinsurance of $203.60. 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 15% of the cost for Medicare-covered diagnostic procedures and tests. You have been asked to pay a total of $203.60 for the electrophysiological evaluation, the intra-cardiac echocardiogram, and the stimulation pacing heart. The electrophysiological evaluation, the intra-cardiac echocardiogram, and the stimulation pacing heart fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
October 8, 2019
Electrophysiological evaluation
$1,064.70
15%
$159.71
October 8, 2019
Intra-cardiac echocardiogram
$140.73
15%
$21.11
October 8, 2019
Stimulation pacing heart
$151.88
15%
$22.78
Total
$203.60
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 electrophysiological evaluation, the intra-cardiac echocardiogram, and the stimulation pacing heart provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia for patient of extreme age and anesthesia for percutaneous image guided procedures on the spine and spinal cord provided on August 23, 2019 by an OON provider.You asked the Plan to pay forthe anesthesia services. You say that as the anesthesia provider, your office is unable to pre-authorize services as the anesthesiologist has not examined the enrollee prior to the surgery or procedure date. You also say that the service was a medical necessity.The Plan denied your request. The Plan says the services were rendered by a non-contracted provider. The Plan also says that prior authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe anesthesia for patient of extreme age and anesthesia for percutaneous image guided procedures on the spine and spinal cord provided on August 23, 2019 by an OON provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement service provided on September 5, 2019.You asked the Plan to waive the copayment for the debridement service. You say that you say you did not receive surgery. You say this was not outpatient and that the doctor has a clinic in the hospital. 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 $275 copayment per visit, per provider, per day for surgery performed in an outpatient hospital setting. You have been asked to pay a $275 copayment for the debridement service. The debridement service falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows that debridement is considered a surgical procedure.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 debridement service provided on September 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly MODERATE to MAX assist for functional gait and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visits provided on October 26, 2019, November 1, 2019 and November 2, 2019.
You asked the Plan to waive the copayment for the ED visits. You say that if the midline was replaced prior to your release from the hospital you wouldn't have returned to the emergency room. You say that you shouldn't be responsible. The Plan denied your request. The Plan says the copayments 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 emergency care. You have been asked to pay a $50 copayment for each ED visit. The total amount you owe is $150 ($50/visit x 3 visits = $150). The ED visits fall within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ED visits provided on October 26, 2019, November 1, 2019 and November 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient lab work provided on August 30, 2019 by an out of network (OON) provider.You asked the Plan to pay foroutpatient lab work. 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 for these services. ThePlan 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 foroutpatient lab work provided on August 30, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 13, 2019 through August 16, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says that the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from August 13, 2019 through August 16, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office consultations (99245) provided on June 27, 2019 through July 30, 2019.You asked the Plan to pay for the office consultations. You say that you would like reconsideration based on the records submitted. The Plandenied your request. The Plan says this provider is privately contracted and not payable by Medicare or the Plan.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at the case file and the Medicare rules. We confirmed that this provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the office consultations have not been met. Therefore, we decided that the Plan does not have to pay for the office consultations (99245) provided on June 27, 2019 through July 30, 2019. Your complaint about receiving incorrect information is not a valid appeal for medical coverage. Thispart of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveYervoy.You asked the Plan to pre-approveYervoy. The Plan denied your request. The Plan says Yervoy has not been approved for the diagnosis of liver cell carcinoma.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Yervoy. Our physician reviewer found that the requested use of Yervoy is not FDA-approved for your diagnosis. The use is not supported by one of the major drug compendia, or by clinical research that appears in a CMS-approved medical journal. The drug is indicated for use one time, but not repeated use, and not after another line of immunotherapy. You progressed on prior regimenon maintenance Nivolumab. Therefore, the requested drug is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met.Therefore, we decided that the Plan does not have to pre-approveYervoy
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe surgical assistant services provided for a lymph node excision/biopsy on September 4, 2019.You asked the Planto pay forthe surgical assistant services. You say that these serviceswere medically necessary and should be paid in full.The Plandenied your request. The Plansaysthe surgical assistant services are not payable for the billed code.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are notcovered. In this case, you billed assistant surgery services for CPT code 38525. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe surgical assistant services provided for a lymph node excision/biopsy on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urine validity testing provided to the enrollee on August 12, 2019.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not separately reimbursable.The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine specimens utilized for drug testing shall not separately bill the validity testing. We looked at the file and Medicare rules.While the drug testing is a covered benefit and has been approved for payment by the plan, the requested validity testing is considered to be part of the drug testing and is not separately billable. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay for the urine validity testing provided to the enrollee on August 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on July 29, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you are requesting reconsideration of the claim based on medical necessity.The Plan denied your request. The Plan says there is no valid referral for this service. You must receive your care from a network provider. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The plan covers emergency care or urgently needed services that you get from an out-of-network provider. You should get prior authorization from the plan prior to seeking care, and the plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.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 thePlan. 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 foran office visit (99214) provided on July 29, 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 the office visit provided on October 12, 2018 by an out of network (OON) provider.You asked the Plan to pay for the physician services. You say that the services were provided to the enrollee in good faith.The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says there was no contact made to the Plan to verify participation status.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the office visit provided on October 12, 2018 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone graft (99999), the interim partial maxillary denture (99999), and the bone replacement graft (99999) provided on February 14, 2019.You asked the Plan to pay forthe dental services. The Plan denied your request. The Plan says the way that the claim lines were submitted with 2 different codes between medical and dental on the same line is not valid.The Plan also says that the claim cannot be processed due to invalid coding.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 99999 is invalid.We find that CPT code 99999 is not supported in the medical record. Specifically,dental claims must be submitted on an American Dental Association (ADA) Claim form, with proper dental procedure codes. The claim that was submitted was on a HCFA with both dental and medical procedure codes. The claim cannot be processed due to invalid coding. Based on this information, we decided that Medicare rules for coverage of the dental services have not been met.Therefore, we decided that the Plan does not have to pay forthe bone graft (99999), the interim partial maxillary denture (99999), and the bone replacement graft (99999) provided on February 14, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit (99204) provided on September 3, 2019.You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plandenied your request. The Plan says that services must be provided according to the Medicare coverage guidelines.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forwardto 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. The Plan did not provide sufficient information to substantiate the denial of services. Therefore, we decided that the Plan has to pay for an office visit (99204) provided on September 3, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on September 13, 2019 by an out of network (OON) provider.You asked the Plan to pay for physical therapy. You say that you were told that these services could be provided out-of-network. You say that you were told to wait for the denial and then appeal for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring physician 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 physical therapy provided on September 13, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora screening mammogram (77067) provided October 3, 2019.You asked the Plan to pay forthe mammogram. You say that the mammogram should be covered.The Plan denied your request. The Plan says coverage is only provided for one screening mammogram annually.The Plan must follow Medicare rules. Medicare rules say that one screening mammogram is covered per year. We looked at the file and Medicare rules. The enrollee already had a screening mammogram within 12 months of the service at issue. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora screening mammogram (77067) provided October 3, 2019.