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

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider on July 13, 2020.You asked the Planto waive the copayment for vision services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for physician/practitioner services/specialty physician. You have been asked to pay a $30 copayment for vision services. Vision services fall within the physician/practitioner services/specialty physician 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 vision services provided by a participating provider on July 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on July 1, 2020.You asked the Plan to pay forthe ambulance services. You say that you treated the enrollee in good faith and did not transport to keep exposure to COVID-19 down.The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 1, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forenteral formula (B4152) enteral feeding supply kit (B4035) provided April 1, 2020 to May 12, 2020.You asked the Plan to pay forthe enteral formula and supplies. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the records do not support the service billed.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 does not contain a valid itemized shipping/billing invoice to indicate the specific supplies or proofof delivery for the supplies provided in this case. In addition, the delivery ticket does not support the unites billed and the shows the dates as 04/02/2020 -04/25/2020. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay forenteral formula (B4152) enteral feeding supply kit (B4035) provided April 1, 2020 to May 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 6, 2020.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the delivery ticket is missing required information.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 does not contain avalid proof of delivery for the supply provided in this case. Review of the file shows that the delivery ticket submitted did not include the carrier's tracking number. In addition, the proof of delivery did not include an order number or details to corroborate the delivery ticket submitted. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 22, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 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 forthe medical services provided on September 22, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe telehealth services provided on June 12, 2020 by an out of network provider.You asked the Plan to pay forthe telehealth services. You say that the service was medically necessary.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require thePlan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe telehealth services provided on June 12, 2020 by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 23, 2020 to July 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that these services were medically necessary and appropriate for the patient.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 forthe medical services provided on June 23, 2020 to July 21, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you did not realize that the provider did not participate with this patient's insurance.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 providerin 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 July 21, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that the enrollee would benefit from care in the LTACH.The Plandenied your request. The Plansaysthere is no clinical advantage to LTACH services over short-term hospital care.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 tocarefully 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 patient is a 55 year old female who was admitted to the current acute care hospital with chest pressure and dyspnea that started after hemodialysis. She became unresponsive and pulseless and was found to be in DKA which caused anoxic brain injury and bacteremia which required antibiotics. She required intubation and required trach and PEG as well as hemodialysis and wound vac to a sacral wound. She was also treated for pneumonia, parapsilosis fungemia, and anemia. Currently, she has been extubated successfully.The patient appears to be gradually improving but requires additional short term acute care services which can safely be performed at the current facility. The patient does not require any services at the LTACH that are not already available at the current facility. Therefore, this request for LTACHservices will be considered not medically necessary. Ongoing treatment at the current facility is appropriate until the patient is able to be transferred to a lower 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe partial lower denture (D5214) provided on August 22, 2020.You asked the Plan to waive the copayment forthe dental item. You say that you were not aware of the $150 copayment. You say that if you had known there was a copayment, you would not have gotten the partial denture.The Plan denied your request. The Plan says there is a $150 copayment for dentures. The Plan also says that the claim processed correctly.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, there is a $150 copayment for dentures. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage.Therefore, we decided that the Plan does not have to waive the copayment forthe partial lower denture (D5214) provided on August 22, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that it is felt that LTACH care is most appropriate.The Plan denied your request. The Plan says there is no advantage to LTACH care for this enrollee.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 there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided by a non-participating provider on August 11, 2020, to August 18, 2020.You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you do not agree with this. The Plan denied your request. The Plan says the correct coinsurance 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 50% coinsurance for inpatient hospitalcare/out-of-network. You have been asked to pay a 50% coinsurance of the allowed amount for an inpatient hospital stay. The total allowed amount is $20,089.47. The total amount you are being asked to pay is less than your 50% coinsurance amount of $10,044.74 ($20,089.47 x 50% = $10.044.74). You have been asked to pay the lesser amount of $7,083.06. An inpatient hospital stay falls within the inpatient hospital care/out-of-network 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 an inpatient hospital stay provided by a non-participating provider on August 11, 2020, to August 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded 76881 provided on August 7, 2020.

You asked the Plan to pay for the ultrasound services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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, the CPT Code Manual definition of code 76881 is ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation. We find that CPT code 76881 is not supported in the medical record. Specifically, this service was provided in a home place of service. This code was not billed with the required modifier 26. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services coded 76881 provided on August 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNFcare. You say that you are not quite ready to go home and it would be beneficial for you to go to a SNF.The Plan denied your request. The Plan says SNF services are 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services withthe specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.You do not have complex wound care or other ongoing SNF level skilled nursing need. Your functional level does not require skilled therapy services withthe specialized skill, knowledge and judgment of a qualified therapistto safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe correction hallux valgus services coded 28298 provided on January 23, 2019.You asked the Plan to pay forthe correction hallux valgus services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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, the CPT Code Manual definition of code 28298 is correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal phalanx osteotomy, any method.We find that CPT code 28298 is not supported in the medical record. Specifically, the operative report did not include documentation of hallux valgus (bunionectomy) correction, with sesamoidectomy, when performed, with proximal phalanx osteotomy, using any method; therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the correction hallux valgus services have not been met.Therefore, we decided that the Plan does not have to pay forthe correction hallux valgus services coded 28298 provided on January 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 current facility can provide for all the enrollee's present inpatient care needs. The enrollee is receiving an appropriate level of care in the present setting.Medicare criteria for transfer to an LTACH are not met. We looked at this physician's review, thefile, 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-approvelong term acute care hospital (LTACH) services forthe enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 21, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that this doctor has been monitoring this patient remotely, so the services were necessary.The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.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 forthe medical services provided on May 21, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug services rendered on May 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code J3490 is not supported.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, the CPT Code Manual definition of code J3490 is unclassified drugs.We find that CPT code J3490 is not supported in the medical record. Specifically, there is no documentation of unclassified drugs for the date of service at issue. 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 forthe drug services rendered on May10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe $30 copayment charged for urgent care services provided on June 13, 2020. You asked the Plan to waivethis copayment. You say that you do not believe this copayment is correct.The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.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 $30 copayment for urgent care services. 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 waivethe $30 copayment charged for urgent care services provided on June 13, 2020