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

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 1, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 1, 2019.You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on April 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the aspiration of a breast cyst or the mammogram provided on September 17, 2019.You asked the Plan to reduce the cost share for the aspiration of a breast cyst and the mammogram. You say that you should only be charged a $300 copayment because all of the services were performed during thesurgical procedure.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 $300 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges and a 20% coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical center).You have been asked to pay a total of $325.45 for the aspiration of a breast cyst and the mammogram. The aspiration of a breast cyst falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The mammogram falls within the "Outpatient Diagnostic Tests and Therapeutic Services and 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 reduce the cost share forthe aspiration of the breast cyst or the mammogram provided on September 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the review indicates that the enrollee was admitted to the emergency department where it was determined that the enrollee suffered an aneurysm. She was brought to the Emergency department on 02/13/2020 via EMS after her husband discovered her on the bathroom floor complaining of generalized weakness and a severe headache, and vomiting. The member underwent a computed tomography which showed a subarachnoid hemorrhage with extension into the ventricular system. The member underwent a computed tomography angiography of the head and neck which showed 0.5 x 0.3 x 0.7 cm saccular aneurysm arising off the V4 segment of the right vertebral artery at the origin of posterior cerebellar artery syndrome (PICA), 3 mm saccular basilar tip aneurysm. The member was sedated and taken to interventional radiology for coiling of the aneurysm. The aneurysm was successfully coiled at 3 points. The member had a follow up CT scan of the head which showed status post coiling of known right vertebral artery aneurysm, mild increase in subarachnoid hemorrhage noted within bilateral sylvian fissure and basal cistern with compared to prior exam. The member had a decline on 02/15/2020 at night and had hypercapnia on arterial blood gas (ABG), however radiology reported 2 mm increase in lateral horns. Neurosurgery placed an external ventricular drain (EVD) as a lifesaving procedure due to blood in the 3rd and 4th. Overnight on 02/21/2020 the member required reintubation again. A repeat CT showed slight worsening of obstructive hydrocephalus. On 03/02/2020 the member underwent a percutaneous tracheostomy tube placement due to multiple attempts at extubating of mechanical ventilation. Medical records dated 03/02/2020 state that the member was started on tube feeding
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe audiology services (92557, 92626, and V5261) provided on October 11, 2019 to October 31, 2019 by an out of network (OON) provider.You asked the Plan to pay forout-of-network audiology services. You say that you did not know this provider was not in-network.The Plan denied your request. The Plan says these services were not authorized.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 audiology services (92557, 92626, and V5261) provided on October 11, 2019 to October 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture rendered on September 27, 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 services are not covered.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. The Plan covers acupuncture only when the person providing the acupuncture is a physician licensed to perform the service.We looked at the file and Medicare rules. The file shows that the provider was not a physician licensed to perform acupuncture. 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 for the acupuncture rendered on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for two knee braces (L1843) provided on July 2, 2019.
You asked the Plan to pay for the two knee braces. You say that you would like reconsideration as you believed this provider was contracted with the Plan. The Plan denied your request. The Plan says knee braces are not a covered benefit when prescribed by a chiropractor.
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 two knee braces (L1843) provided on July 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that thePlan does not have to pre-approve Tretinoin cream.You asked the Plan to pre-approveTretinoin cream. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of youPart D prescription drug plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveTretinoin cream.Benefits for Tretinoin creammay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical oncology evaluation to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a medical oncology evaluation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified higher level of care tertiary centers that are in-network available to the enrollee that can provide the services being requested.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a medical oncology evaluation to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 24 additional physical therapy visits.
You asked the Plan to pre-approve the 24 additional physical therapy visits. You say that the records provided support the need for the physical therapy visits requested. The Plan denied your request. The Plan says the additional physical therapy visits being requested are not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 the 24 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found a recommended course of physical therapy for the enrollee's condition could be expected to include up to 9 therapy treatment sessions. Goals can usually be achieved with fewer than the number of treatments recommended. At this point, either the enrollee would be expected to have achieved his goals or they would have been modified to reflect achievable and realistic goals within a reasonable timeframe. The requested additional therapy would not be accepted as specific and effective at this point in the enrollee's treatment. The enrollee has already had physical therapy treatments well in excess of that recommended, and these have included instruction in a home exercise program. The enrollee should be able to independently perform an ongoing home exercise program which could include use of TheraBands and a home pulley system for strengthening and range of motion. Home exercises are available and effective. A regularly performed home exercise program would best meet this enrollee's needs. Ongoing skilled therapy services are 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 the 24 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 24 additional physical therapy visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 24, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that 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 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 laboratory services provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on September 26, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that these services were medically necessary and you would like this claim approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available 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 fromout-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 foran office visit provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance services provided on June 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the ambulance service. You say that please review the facility to facility medically necessary services and reconsider for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 BLS non-emergency ambulance services provided on June 17, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Planhasto pre-approvea Synvisc-One injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthere is no information on how the knee pain affects activities of daily living.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 the injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found [state the medical finding(s) upon which the physician based his/her conclusion]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 injection have been met.Therefore, we decided that the Planhas to pre-approvea Synvisc-One injection for the enrollee.If the Plandoes 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/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 8, 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 records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the an Inogen One G4 portable oxygen concentrator to be provided by an out of network provider.You asked the Plan to pre-approve an out-of-network portable oxygen concentrator. You say that your current portable oxygen concentrator is too heavy.The Plan denied your request. The Plan says portable oxygen concentrators are available 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the an Inogen One G4 portable oxygen concentrator to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided on October 14, 2019.
You asked the Plan to waive the copayment for an injection. You say that you did not have any surgery. You say that you paid your office visit copayment and that should be all you owe. 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 $290 copayment for outpatient surgery. You have been asked to pay $265.95 which is less than your copayment amount of $290 for an injection. The injection you received is considered an outpatient surgery; therefore, the correct copayment has been applied. The injection you received falls within the outpatient surgery 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 injection provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on June 27, 2019 by an out of network (OON) provider.You asked the Plan to pay fora specialist office visit. You say that these services were referred to your mom after being discharged from the hospital due to a double pelvic fracture.The Plan denied your request. The Plan says these services were self-referred. The Plan says that no prior authorization was obtained 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 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 fora specialist office visit provided on June 27, 2019 by an out of network (OON) provider.