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

We decided that the Plan does not have to pay for the medical services provided on December 6, 2019 by a
non-network provider.
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 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 referring provider 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 December 6, 2019 by a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (CPT 98943) provided to the enrollee on January 3, 2020.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this service is covered only to treat subluxation of the spine. 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 chiropractic services (CPT 98943) provided to the enrollee on January 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the Lower Extremity (73718) provided December 12, 2019.
You asked the Plan to pay for the MRI. You say that services were medically necessary and correctly billed. The Plan denied your request. The Plan says services were billed with an incorrect place of 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 73718 is not supported in the medical record. Specifically, the claim was submitted with an outpatient place of service, however records show this was while the enrollee was admitted as an inpatient. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for Magnetic Resonance Imaging (MRI) of the Lower Extremity (73718) provided December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral surgery evaluation rendered on October 3, 2019.
You asked the Plan to pay for these services. You say that this was the only oral surgeon in the area, and you thought the services would be covered. The Plan denied your request. The Plan says the services are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the oral surgery evaluation rendered on October 3, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
December 15, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the service should be
covered by the Plan because your plan was active and you did not know you would have to pay out-of-pocket.
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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" 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
emergency room visit provided on December 15, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.You asked the Plan to pre-approve home health services. You say that your feelings were not being taken in to consideration.The Plan denied your request. The Plan says there are no attainable goals in therapy, and no other skilled services are needed.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our physician reviewer found that the records do not show that skilled therapy services are required to effectively provide treatment, care, or services in order to improve your level of function, or to establish a maintenance program to maintain your level of function or prevent deterioration. You have no skilled goals, have been non-compliant with prior therapy, and have no need for ongoing skilled physical therapy in the home.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on December 18, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges because this was your annual wellness visit. 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 $25 copayment for each primary care provider visit. The medical records show that you received services beyond an annual wellness exam on December 18, 2019. Therefore, you are responsible to pay the $25 copayment. You have been asked to pay a $25 copayment for an office visit. An office visit 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 an office visit provided on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group adult foster care.
You asked the Plan to pre-approve the group adult foster care services. You say that the enrollee does not live with family. You say that the enrollee is not receiving the help she needs. The Plan denied your request. The Plan says the enrollee does not have a medical, cognitive, or behavioral-health related condition that impairs her ability to independently complete Activities of Daily Living (ADLs).
The Plan must follow Medicare rules. Medicare rules say that custodial care is not a Medicare covered benefit. We looked at the file and Medicare rules. The records show that the services in dispute are to provide personal care that does not require supervision or attention of trained medical caregivers. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve group adult foster care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services rendered on November 15, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you were inpatient. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Medicare-covered surgery or other services provided to you at an outpatient hospital.
Review of the file shows that you received outpatient surgical services on November 15, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $306.79. These services fall within the Medicare-covered surgery or other services provided to you at an outpatient hospital 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 outpatient surgery services rendered on November 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional outpatient occupational therapy visits.
You asked the Plan to pre-approve the 4 additional outpatient occupational therapy visits. You say that the
records provided support the need for the requested occupational therapy visits. The Plan denied your request.
The Plan says the clinical documentation does not support the need for ongoing therapy.
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 4 additional outpatient occupational
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 the enrollee has already had
occupational therapy treatments without new injury or impairing condition. At this point, either the enrollee
would be expected to have achieved her goals or they would have been modified to reflect achievable and
realistic goals within a reasonable timeframe. Applying Kinesiotape would not be effective in treating lower
extremity swelling and there are appropriate and effective treatments including use of compressive stockings.
The requested additional occupational therapy would not be accepted as specific and effective at this point in
the member's treatment. The enrollee should have already had instruction in a home exercise program and has
caregiver assistance available. Ongoing skilled occupational 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 4 additional outpatient occupational therapy visits have not been met.
Therefore, we decided that the Plan does not have to pre-approve 4 additional outpatient occupational therapy
visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services rendered on June 13, 2019.
You asked the Plan to waive the copayment for these services. You say that you don't feel liable for the copayment. The Plan denied your request. The Plan says the copayment was 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 $65 copayment for Medicare-covered urgently needed care visits.
Review of the file shows that you received urgent care services on June 13, 2019. You have been asked to pay a $65 copayment for these services. These services fall within the Medicare-covered urgently needed care 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 the urgent care services rendered on June 13, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a thromboembolic stroke. The enrollee is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the A1c testing rendered on January 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that A1c testing is medically necessary for the
management and control of diabetes.
We looked at the file and Medicare rules. The file shows that the testing was performed for a diagnosis of
anemia. 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 A1c testing rendered on January 17,
2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Myocardial strain imaging (0399T) provided November 13, 2019.
You asked the Plan to pay for the Myocardial strain imaging. You say that the service was medically necessary. The Plan denied your request. The Plan says this service is not a covered 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 0399T is not supported in the medical record. Specifically, Medicare rules state that CPT code 0399T is considered not medically necessary. Based on this information, we decided that Medicare rules for coverage of the Myocardial strain imaging have not been met. Therefore, we decided that the Plan does not have to pay for Myocardial strain imaging (0399T) provided November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on November 26, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on December 23, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were seen for a follow-up for ongoing medical issues. The Plan denied your request. The Plan says your claim was reprocessed and 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 $10 copayment for all covered services, per visit if performed at your PCP's 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. 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 December 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on August 27, 2019.
You asked the Plan to pay for non-emergent ambulance services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient on August 27, 2019. She could not tolerate a seated position but could have been transported by stretcher van. The documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on August 27, 2019. The documentation does not support that the ambulance transport on August 27, 2019 was medically reasonable and necessary for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance services provided to the enrollee on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture provided on February 26,
2020.
You asked the Plan to pay for the complete maxillary denture. You say that you began the process of replacing
your defective denture in 2019. You also say that the Plan denied the payment due to changes in the 2020
benefits. The Plan denied your request. The Plan says this service is not a covered benefit.
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
complete maxillary denture provided on February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 25, 2019 through November 29, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from November 25, 2019 through November 29, 2019 provided by an in-network provider. You were asked to pay a $370 copayment per day from November 25, 2019 through November 28, 2019, days 1-4 of your inpatient hospital care. You were discharged on November 29, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $370 copayment per day required for days 1-5 for in-network inpatient hospital care. 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 inpatient hospital care from November 25, 2019 through November 29, 2019.