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

We decided that the Plan does not have to pay for the acupuncture (97813, 97814) provided from April 26, 2019 to May 17, 2019.You asked the Plan to pay for these services. You say that the services were medically necessary and essential to the enrollee's care.The Plan denied your request. The Plan says the acupuncture services were not provided by a doctor of medicine, therefore the service is not covered under the member's policy.The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Specifically, the acupuncture services were not provided by a licensed physician. The services were rendered by the physician who is licensed to provide acupuncture therapy. Therefore, we decided that the Plan does not have to pay for the acupuncture (97813, 97814) provided from April 26, 2019 to May 17, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 21, 2019 to August 22, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that inpatient care was medically necessary.The Plan denied your request. The Plan says that these services could have been provided at a lower level of care.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 enrollee presented to the emergency department on August 16, 2019 with vertigo and gait instability despite four days of Meclizine therapy. The evaluation demonstrated chronic lacunar infarct in the left basal ganglia. She was treated with IV Zofran and oral Meclizine. She was diagnosed with vestibular neuritis and placed on oral Prednisone. She required IV fluids and received physical therapy. She was discharged home on August 23, 2019 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 forthe acute inpatient hospital care provided from August 21, 2019 to August 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided June 20, 2019 to June 21, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this inpatient hospital care was not medically necessary and the enrollee could have been treated in the emergency room or an outpatient setting.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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span 2 midnights. Removal of the percutaneous endoscopic gastronomy (PEG) tube was uncomplicated and all medically necessary care was provided in a time period of less than 2 midnights. Therefore, this inpatient admission was not medically 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 acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided June 20, 2019 to June 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forLow Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297) provided August 26, 2019.You asked the Plan to pay forthe Lung Cancer Screening. You say that the services were medically necessary.The Plan denied your request. The Plan says only one LDCT Lung Cancer Screening can be covered in a 12 month period.The Plan must follow Medicare rules. Medicare rules say that LDCT Lung Cancer Screenings are covered for suitable enrollees on an annual basis. Plan rules limiting coverage to one screening per 12-month period are consistent with Medicare coverage rules. We looked at the file and Medicare rules. A Screening was already provided and covered within the past 12 months for the enrollee. Based on this information, we decided that Medicare rules for coverage of the Lung Cancer Screening have not been met.Therefore, we decided that the Plan does not have to pay forLow Dose Computed Tomography (LDCT) Lung Cancer Screening (G0297) provided August 26, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forRadiology Services (70450) provided June 12, 2019 by "the provider". You asked the Plan to pay forthe radiology services. You say that the services were medically necessary and properly billed.The Plan denied your request. The Plan says the code at issue shares a column I / column II relationship with another code billed on the same date of service for this enrollee.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forRadiology Services (70450) provided June 12, 2019 by "the provider".
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forRadiology services (70450) provided August 31, 2019 by "the provider" .You asked the Plan to pay forthe radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the records submitted do not support the services billed.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 70450 is not supported in the medical record. Specifically, the records provided do not include the name of the patient. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met.Therefore, we decided that the Plan does not haveto pay forRadiology services (70450) provided August 31, 2019 by "the provider".
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided.
You asked the Plan to waive the copayment for the colonoscopy. You say that you should not be charged for having a polyp removed. You say that you cannot afford it. 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 $250 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that a polyp was removed. 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 colonoscopy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 7, 2019 by the out of network provider.You asked the Plan to pay for the physician services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent in nature.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 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 June 7, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by out of network provider.You asked the Plan to pay for specialist service. You say that it is the facility's responsibility to obtain authorization, and the enrollee was in dire need of service.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe inpatient stay provided from March 28, 2019 to April 2, 2019.You asked the Plan to reduce the copayment forthe inpatient stay. You say that you should not be responsible for the copayment because you wanted to leave the hospital sooner. 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 $360 copayment per day, days 1-5 and a $0 copayment per day, days 6-90. You have been asked to pay a $360 copayment for each day of the inpatient stay. ($360 x 5 days = $1,800). The inpatient stay falls within the "Inpatient hospital care" benefit category. The record shows you were admitted on March 28, 2019 and discharged on April 2, 2019.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 copayment fortheinpatient stay provided March 28, 2019 to April 2, 2019.Your complaint that you were held against your will is not a valid appeal for medical coverage. This part 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by the Provider on April 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 medical services provided to to the enrollee by the Provider on April 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 6, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 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 medical services provided by an out-of-network provider on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 15, 2019.You asked the Plan to pay for the medical services. You say that it is not possible to requested authorization before services are rendered.The Plan denied your request. The Plan says there is no network deficiency for these services.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 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 forthese services.Therefore, we decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on July 17, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are included in the facility DRG payment.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. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided on July 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies provided by the practice from July 11, 2019 to September 29, 2019.
You asked the Plan to pay for diabetic supplies. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the delivery ticket submitted did not include the carrier's tracking number nor did the proof of delivery include an order number or details to corroborate the delivery ticket.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider payment for any item, the information submitted by the supplier must corroborate the documentation in the medical record. The rules say that the supplier must furnish to the Plan sufficient information to determine whether payment is due. We looked at the file and Medicare rules. The delivery ticket submitted is not signed by the recipient, nor is the delivery ticket corroborated by the proof of delivery submitted. Therefore, you have not furnished sufficient information to the Plan to justify coverage of this claim as billed. Based on this information, we decided that Medicare rules for coverage of diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pay for diabetic supplies provided by the practice from July 11, 2019 to September 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by an out-of-network provider.
You asked the Plan to pay for the out-of-network services. You say that the notes support the need to have the service multiple times. The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate network providers were found.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 4, 2019 to October 23, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 4, 2019 to October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on May 30, 2019.
You asked the Plan to pay for the lab services. You say that the medical records are not supplied to the laboratory. The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of the testing.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on May 30, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride on August 20, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you should not be responsible for the copayment because it was an emergency and there was no gynecologist on staff to treat you at the first 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 $175 copayment for Medicare-covered one-way ground ambulance benefit. You have been asked to pay a $175 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance ride on August 20, 2019.