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

We decided that the Plan does not have to waive the copayment for a stress test provided by a participating provider on February 24, 2021.
You asked the Plan to waive the copayment for a stress test. You say that you do not agree with this copayment. 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 $100 copayment for outpatient diagnostic tests/nuclear medicine. You have been asked to pay a $100 copayment for a stress test. The correct copayment has been applied to the nuclear stress test that was provided. A stress test falls within the outpatient diagnostic tests/nuclear medicine 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 stress test provided by a participating provider on February 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) admission.
You asked the Plan to pay for SNF admission. The Plan denied your request. The Plan says SNF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that based on review of the available limited records, the enrollee does not meet the CMS coverage criteria for an admission to a SNF due to lack of documentation substantiating a need for nursing care, and no supporting documentation requiring daily therapies in an inpatient setting when the enrollee is not making much progress. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on April 6, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you had a preventive visit, and you are being charged a $10 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $10 copayment for an in-network primary care provider (PCP)/other health care professional office visit.
You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were seen for a follow-up for conditions such as hypertensive chronic kidney disease and low back pain in addition to the routine exam.
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 office visit provided on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee arthroplasty revision (27487) provided by a registered
nurse on April 6, 2021.
You asked the Plan to pay for a knee arthroplasty revision. You say that this should be covered because the
surgeon was in-network. The Plan denied your request. The Plan says this provider type is not eligible for
Medicare enrollment or payment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program. Registered Nurses frequently attempt to enroll in Medicare, but are not
eligible to do so. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for a knee arthroplasty revision (27487)
provided by a registered nurse on April 6, 2021.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says that the enrollee does not require daily skilled nursing services such as the
administration of intravenous (IV) antibiotics, management and education of a new PEG tube or colostomy, or
complex wound care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the
requested SNF admission is medically reasonable and necessary. Our physician reviewer found the enrollee is a
male who presented to the hospital on 8/15/2021 after a fall, requiring surgical repair of a left hip fracture. He
is weak and unsteady and is working with physical and occupational therapy. He is walking with a rolling
walker 150 feet with supervision and is contact guard assist for transfers and some activities of daily living
though he is totally dependent for bathing and toileting. Physical therapy and occupational therapy recommend
daily therapy treatments in a skilled facility.
Based on the medical records provided, there is no documentation that the patient requires skilled nursing
services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to
safely and effectively provide medically necessary and reasonable treatment. However, there is documentation
of a need for skilled therapy services. The records support that daily therapy is required in this case. As a
practical matter, the enrollee requires these services on an inpatient basis in the facility setting. The enrollee is
totally dependent for toileting and bathing, and therapy notes consistently document daily therapy 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 SNF care have been met.
The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the
service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided
that the Plan has to pre-approve skilled nursing facility (SNF) care.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 was admitted for weakness, acute kidney injury and hypocalcemia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided October 6, 2020.
You asked the Plan to pay for the electrocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 93010 is not supported in the medical record. Specifically, a required modifier was not applied to denote the same service performed on the same day by a different provider. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided October 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on April 21, 2021 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that this enrollee resides in a nursing home and your provider provides acute visits to the nursing home. You also say that these claims would not need authorization under traditional Medicare. The Plan denied your request. The Plan says 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 for the subsequent nursing facility care provided on April 21, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 9, 2021.
You asked the Plan to pay for the limited evaluation. You say that this service was necessary as you were still having problems with the tooth. You feel this service should be covered as you have not met your $1,000 annual maximum and you are still experiencing pain. The Plan denied your request. The Plan says this service can only be covered once per year. You previously had a limited exam in March of 2021, which was covered by the Plan. Therefore, payment will not be made.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan will cover up to one
limited oral evaluation per plan year. Though the Plan offers a dental benefit in excess of Medicare coverage, the evaluation is requested in a frequency that is not covered under this benefit. Documentation supports that you had a previous limited evaluation in 2021, which was covered by the Plan. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on April 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to make additional payment for inpatient services provided to the enrollee from February 28, 2021, to March 7, 2021.
You asked the Plan to make additional payment for inpatient services. You say that the Plan reduced payment based on the diagnosis-related group (DRG) they believed was appropriate, which was not correct. The Plan denied your request. The Plan says that per the medical records provided, changing the DRG was appropriate.
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. The notes in the case file from the Plan and a screen shot provided by the Plan states that based on review of the medical records, their decision to change the DRG code and reduce payment was correct. However, the Plan did not include any medical records in the case file for review. Without medical records, we cannot substantiate the Plans denial. Therefore, we decided that the Plan has to make additional payment for inpatient services provided to the enrollee from February 28, 2021, to March 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 14, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Per Medicare PTP Coding Edits and National Correct Coding Initiative Edits guidelines, an un-bundled relationship exists between billed codes 81298 XS, 81295 XS and 81432 and there is no modifier allowed.
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, this claim cannot be paid as billed due to the un-bundled relationship between each code. Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0272), and prophylaxis (D1110) provided on March 22, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you were not aware that the treating provider was not in-network at the time of these services. The Plan denied your request. The Plan says these services were rendered by an OON provider and are not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0272), and prophylaxis (D1110) provided on March 22, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided March 30, 2021.
You asked the Plan to pay for the limited oral exam. You say that you were not told the dentist was performing a limited oral exam. The Plan denied your request. The Plan says this service is not covered under your 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 limited oral evaluation - problem focused (D0140) provided March 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an
outpatient hospital facility on April 14, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a required
procedure because you had rectal bleeding and severe stomach pain. The Plan denied your request. The Plan
says you were charged this copayment 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 $250
copayment for outpatient surgery at an outpatient hospital facility.
You have been asked to pay a $250 copayment for the diagnostic colonoscopy. Diagnostic colonoscopies are
considered surgical services, so this procedure falls within the outpatient surgery at an outpatient hospital
facility 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 diagnostic colonoscopy you
had at an outpatient hospital facility on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the genetic testing. You say that the service is medically necessary, and the Plan must cover what Original Medicare covers. The Plan denied your request. The Plan says no prior authorization was 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 for genetic testing provided on March 26, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for posterior tibial neurostimulation provided on May 5, 2021.
You asked the Plan to waive the copayment for posterior tibial neurostimulation. You say that the Plan agreed to waive the copayments for the treatments. 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 specialist services. You have been asked to pay a $30 copayment for posterior tibial neurostimulation. Posterior tibial neurostimulation falls within the physician/practitioner services including doctor's office visits 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 posterior tibial neurostimulation provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a generator (E1399).
You asked the Plan to pre-approve the generator. You say that this is needed in case the power goes out. The Plan denied your request. The Plan says the documentation fails to indicate that this request would be considered durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a generator (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for a lower intestinal endoscopic procedure (00811 x 2) rendered by the out-of-network (OON) provider on January 20, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the anesthesia for a lower intestinal endoscopic procedure (00811 x 2) rendered by the out-of-network (OON) provider on January 20, 2021.