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

We decided that the Plan does not have to pay for physician's services provided on August 7, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 15, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient hospital stay provided from September 28, 2019 to October 3, 2019.
You asked the Plan to pay for an inpatient hospital stay. You say that based on the clinical facts presented at the time of presentation, the services provided were appropriate at the level of care provided. The Plan denied your request. The Plan says the patient was admitted to the hospital from the emergency room for stabilization care without the required authorization from the physician medical group.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 an inpatient hospital stay. Our reviewer says that the service was not medically necessary. Our physician reviewer found that the enrollee was sent to the Emergency Department (ED) on September 28, 2019 due to abdominal pain, nausea, vomiting and poor oral intake. Vital sign measurement was significant for hypertension. Her pain level was 7/10. A computed tomography (CT) scan of the abdomen revealed multiple pulmonary nodules, right-sided effusion, multiple liver lesions, biliary stent and pancreatic head mass.
The enrollee was treated with intravenous (IV) fluids. She was subsequently admitted as an inpatient to the facility with an impression of pancreatic cancer with metastases and hyponatremia. Intravenous fluids continued and home medications were resumed. The attending physician documented do not resuscitate (DNR) status and recommended hospice evaluation. The enrollee improved clinically and was discharged to a skilled nursing facility in stable condition on October 3, 2019. The review has determined that the enrollee was stable and appropriate for ambulance transport with monitoring to a Plan facility for admission level of care services after the emergency room evaluation on September 28, 2019. The post-stabilization care services September 28, 2019 to October 3, 2019 were not medically necessary and reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient hospital stay have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital stay provided  from September 28, 2019 to October 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diabetic shoes, the diabetic inserts and the repair of the orthotic device provided on August 1, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you cannot afford to pay these charges. The Plan denied your request. The Plan says that you were charged the correct cost-sharing.
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% coinsurance for Medicare-covered diabetic therapeutic shoes or inserts and a 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 35% coinsurance for the diabetic shoes and the diabetic inserts and a 20% coinsurance for the repair of the orthotic device. The diabetic shoes and the diabetic inserts fall within the Medicare-covered diabetic therapeutic shoes or inserts benefit category and the repair of the orthotic device falls within the Durable medical equipment (DME) and related supplies 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 the diabetic shoes, the diabetic inserts and the repair of the orthotic device provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 28, 2019.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 correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on August 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.You asked the Plan to pre-approve these services. You say that you are not strong enough to go home.The Plan denied your request. The Plan says the 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 above 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital with shortness of breath and cough. You received physical and occupational therapy in the hospital and need assistance with walking 40 feet with a rolling walker. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray provided to the enrollee on September 21, 2019.
You asked the Plan to pay for the x-ray. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records are insufficient, and the place of service is invalid.
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 x-ray. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the dictated reason for the exam - shortness of breath - does not qualify for a reason for the exam, absent appropriate medical records and written order from the clinician. 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 x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray provided to the enrollee on September 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that the enrollee has problems walking because her shoes are uncomfortable and cause pressure on her feet. You stated that she needs to be able to move around to maintain her independence and the requested orthotics are medically necessary for the enrollee's various medical conditions. You say the enrollee would benefit from the requested orthotics.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for equipment assembly billed to the enrollee on October 1,
2019 during an inpatient admission.
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 this claim was submitted directly to the Plan in error.
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. This equipment was used during an inpatient stay. Payment for this service would have been
included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital.
Therefore, we decided that the Plan does not have to pay for equipment assembly billed to the enrollee on
October 1, 2019 during an inpatient admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have been wearing shoe orthotics for about forty five years and you need them to maintain your quality of life. You stated that you have falling arches and the orthotics help slow or stop the falling and subsequent damage to your feet. You say that your previous Plan approved the requested orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Lab
Decision: Unfavorable

e decided that the Plandoes not haveto pay forlab services provided to the enrollee on June 3, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthere is evidence of misrepresented services.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 codes 88237, 88264, 88280, and 88291 is not supported in the medical record. Specifically, the appealing provider has submitted claims to the plan for these codes using an address for a laboratory that they do not have. There is no evidence that the provider has a laboratory at the address submitted. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services provided to the enrollee on June 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a sigmoidoscopy (45331) provided on August 2, 2019.You asked the Plan to pay for the sigmoidoscopy. You say that you would like reconsideration as these services were medically necessary. The Plan denied your request. The Plan says there is no evidence that stool studies were performed or documented.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 sigmoidoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found preliminary testing most appropriately include stool analysis for enteric pathogens and occult blood but available records do not show these studies were performed prior to the service in question.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 sigmoidoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a sigmoidoscopy (45331) provided on August 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 27,
2019 to June 30, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF
services. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of
coverage were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing
service needs and skilled therapy service needs but does not require skilled therapy on a daily basis. The
enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 27, 2019 to June 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea power mobility device.You asked the Plan to providea power mobility device. You say that a power mobility device is medically necessary for the enrollee.The Plan denied yourrequest. The Plan says there is no documentation supporting medical necessity, there is no face-to-face examinationrecord, and there is no 7 Element Physician Order.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating therequested PMD. The file does not showthat the enrollee hasa mobility deficit that impairs their participation in MRADLs, theircondition cannotbe improved by a walker, cane or manual wheelchair, and they can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to providea power mobility device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese 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 forthe medical services provided on August 6, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation and oral surgery.You asked the Plan to pre-approvethe dental services. The Plan denied your request. The Plan says the services requested are not covered benefits under your plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit.Therefore, we decided that the Plandoes not have to pre-approvegingival irrigation and oral surgery.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe observation stay provided on October 10, 2019.You asked the Plan to waive the copayment forthe observation stay. You say that you did not qualify for admission. You say that you do not agree with the copayment.The Plan denied your request. The Plan says the copayment 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 $200 copayment for each Medicare-covered outpatient hospital facility visit, clinic, outpatient treatment room, observation room, or outpatient surgery services.You have been asked to pay a $200 copayment for the observation stay. The observationstay falls within the "Outpatient Hospital Services" benefit category. The records show that you were discharged after being admitted to outpatient observation. 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 forthe observation stay provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician service. You say that the provider relies on the hospital staff to verify the enrollee's eligibility and to obtain the necessary and proper authorizations. You also 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 the services were not urgent or emergent in nature. The Plan also says the services could have been provided in 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 the domiciliary visit provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Inogen IS-400 G4 system purchased from Inogen on August 5, 2019.You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you could not wait for a DME provider to figure out your insurance.The Plan denied your request. The Plan says you must have prior authorization and use a network provider.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare rules say that only rented oxygen equipment is eligible for coverage.Purchased oxygen equipment is statutorily non-covered by Medicare.The Plan did not pre-approve the item/service at issue.Therefore, we decided that the Plan does not have to reimburse you for the Inogen IS-400 G4 system purchased from Inogen on August 5, 2019.