Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) provided on May 9, 2018.
You asked the Plan to pay for the office visit. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy.
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 the office visit (99213) provided on May 9, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on June 13, 2018 to June 14, 2018.You asked the Plan to waive the copayment foran x-ray. You say that this services happened two years ago. You say that the hospital and the plan need to figure this out. 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 $30 copayment for outpatient diagnostic tests/x-ray. You have been asked to pay $10.49 which is less than your copayment amount of $30 for an x-ray. An x-ray falls within the outpatient diagnostic tests/x-ray 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 an x-ray provided by a participating provider on June 13, 2018 to June 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 26, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenitrous oxide (D9230) other drugs and/or medicines (D9630) alveoloplastyin conjunction with extractions (D7310) oral/facial photography (D0350) tooth molds (D0470) and bone graft, tooth 30 (D6104).You asked the Plan to pre-approvethe dental services. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says these services are not covered under the plan 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 doesnot have to pre-approvenitrous oxide (D9230) other drugs and/or medicines (D9630) alveoloplasty in conjunction with extractions (D7310) oral/facial photography (D0350) tooth molds (D0470) and bone graft, tooth 30 (D6104).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for educational supplies (99071) provided on December 2, 2019.
You asked the Plan to pay for the educational supplies. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says this code is included in the payment of the
other services performed on the same date of service, for the same patient, and by the same provider and is not
separately reimbursable.
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 99071 is educational supplies, such as books, tapes, and
pamphlets, for the patient's education at cost to physician or other qualified health care professional.
We find that CPT code 99071 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 99071 has a status code of B. This means that the payment for CPT code 99071 is always bundled into
another service. CPT code 99071 is not separately reimbursable. Based on this information, we decided that
Medicare rules for coverage of the educational supplies have not been met. Therefore, we decided that the Plan
does not have to pay for educational supplies (99071) provided on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 17, 2020.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on December 19, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on December 19, 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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.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 required minimal to moderate assistance for grooming. The enrollee required stand-by assistance for feeding. The enrollee required minimal/maximum assistance for dressing. The enrollee was total dependent for toileting. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program.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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have eight herniated discs, prior cervical fusion surgery, a pacemaker, and a replaced right rib. It is not clear that you are homebound. The records do not support that you need skilled nursing or skilled therapy services. Home health aide services are not reasonable or medically necessary for treatment of your illness or injury.We looked at this physician's review, the file, and Medicare rules. 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 pre-approve home health aide services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora fine needle aspiration biopsy provided on January 30, 2020.You asked the Plan to waive the coinsurance fora fine needle aspiration biopsy. You say that you disagree with the charges because the biopsy was not successful.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received a fine needle aspiration biopsy on January 30, 2020. The total allowed amount is $1,142.93 and 10% of that is $114.30. You have been asked to pay the total coinsurance amount of $114.30 for a fine needle aspiration biopsy. A fine needle aspiration biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora fine needle aspiration biopsy provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for educational supplies (99071) provided on December 20,
2019.
You asked the Plan to pay for the educational supplies. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says this code is included in the payment of the
other services performed on the same date of service, for the same patient, and by the same provider and is not
separately reimbursable.
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 99071 is educational supplies, such as books, tapes, and
pamphlets, for the patient's education at cost to physician or other qualified health care professional.
We find that CPT code 99071 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT
code 99071 has a status code of B. This means payment for this service is always bundled into the payment for
another service. CPT code 99071 is not separately reimbursable. Based on this information, we decided that
Medicare rules for coverage of the educational supplies have not been met. Therefore, we decided that the Plan
does not have to pay for educational supplies (99071) provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital intermediate intensive care unit (ICU) care
provided from June 25, 2019 to June 27, 2019.
You asked the Plan to pay for the inpatient intermediate ICU care. You say that the enrollee was provided with
the appropriate level of care based on his condition. The Plan denied your request. The Plan says that this stay
was approved at the standard inpatient level of care. This was billed with revenue code 0206 which was not
shown to be medically necessary.
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 pay for the inpatient intermediate ICU care. Our
reviewer says that the requested services are considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was a then 103 year old male with a history of COPD and atrial
fibrillation. He presented to the ED on 6/26/19 with an exacerbation of COPD. The evaluation revealed rate
controlled atrial fibrillation and question of pneumonia. The troponin was elevated. He was treated with
nebulizer treatments and antibiotics. He was admitted to telemetry. The review has determined that the
documentation supported that placement in intermediate ICU was medically reasonable and necessary rather
than general inpatient placement. The enrollee was appropriate for telemetry monitoring after the emergency
room evaluation. The telemetry monitoring was medically necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the inpatient intermediate ICU care have been met. Therefore, we decided that
the Plan has to pay for the inpatient hospital intermediate intensive care unit (ICU) care provided from June 25,
2019 to June 27, 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: 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 care is medically necessary. The Plan denied
your request. The Plan says Medicare coverage criteria for IRF care are not 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 based on the documentation provided, your condition does not require the intensity of
services provided at an IRF. Specifically, the records do not show that you are able to perform fifteen hours per
week of rehabilitative services with regular physician evaluation.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections provided by a participating provider on January 13, 2020.You asked the Plan to waive the coinsurance for injections. You say that you thought this would be covered completely. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for injections. The total allowed amount is $52.43. The total amount you are being asked to pay is $10.49 ($52.43 x 20% = $10.49). Injections fall within the Medicare Part B prescription 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 injections provided by a participating provider on January 13, 2020.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says Medicare criteria for IRF care are not 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 based on the documentation provided, the enrollee does not require the intensity of
services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of
rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 6, 2020.
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 screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on February 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for an X-ray study of swallowing function and the evaluation provided on March 16, 2020.
You asked the Plan to reduce the copayments for an X-ray study of swallowing function and the evaluation. You say that you should only owe a $30 copayment not a $45 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for X-rays. Your contract with the Plan also clearly says that you must pay a $15 copayment for outpatient rehabilitation services. You received an X-ray study of swallowing function on March 16, 2020. Therefore, you are responsible to pay the $30 copayment. You received a speech therapy evaluation of an X-ray study of swallowing function on March 16, 2020. Therefore, you are responsible to pay the $15 copayment. The total amount you owe is: $45. You have been asked to pay the total copayment amount of $45 for an X-ray study of swallowing function and the evaluation. An X-ray study of swallowing function falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. The evaluation of an X-ray study of swallowing function falls within the outpatient rehabilitation 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 reduce the copayments for an X-ray study of swallowing function and the evaluation provided on March 16, 2020.