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

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the
enrollee on September 23, 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 documentation submitted did not include a valid physician order/lab requisition or medical
records (signed by the ordering physician); therefore the billed code cannot be verified.
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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1)
drug identification methods able to identify individual drugs and distinguish between structural isomers (but
not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS
(any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic
methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in
all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method
or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument
variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing,
per day; 22 or more drug class(es), including metabolite(s) if performed."
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found a test
order form for the date of service was provided; however, the enrollee's name was not listed on it to connect it
to the enrollee in question. The order is invalid.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing services (HCPCS G0483) provided to the enrollee on September 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care from January 17, 2020 to February 10, 2020.
You asked the Plan to pay for inpatient mental health. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee no longer required inpatient care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health. Our reviewer says that the criteria for coverage of inpatient care have not been met for the dates at issue. Our physician reviewer found based on the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to
safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. The health plan's denial of continued inpatient psychiatric services is appropriate. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care from January 17, 2020 to February 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on February 18, 2020 from a nonparticipating
provider.
You asked the Plan to pay for the hearing aids. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
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.
Review of the file show that you purchased hearing aids on February 18, 2020 from a non-participating
provider. Your EOC states, out-of-network hearing aids are not covered. 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 hearing aids purchased on February 18, 2020 from a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 23, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 a domiciliary, rest home visit provided on November 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $20 copayments charged for physician visits on May 9,
2020 and May 10, 2020.
You asked the Plan to waive these copayments. You say that you do not believe you should have to pay these
copayments. The Plan denied your request. The Plan says these copayments were charged per your Plan
contract agreement and the claim submitted by your provider.
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 $20
copayment for physician visits. 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 $20 copayments charged for physician visits on May 9,
2020 and May 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient hospital services provided by an in-network hospital on December 5, 2019 to December 10, 2019.You asked the Plan to waive the copayment for outpatient hospital services. You say that you feel like this is being billed incorrectly. 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 $200 copayment for outpatient surgery/outpatient hospital. You have been asked to pay less than a $200 copayment for each outpatient hospital services. The total amount you are being asked to pay is $546.90 ($182.30 x 3 visits = $546.90). Outpatient hospital services falls within the outpatient surgery/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 copayment for outpatient hospital services provided by an in-network hospital on December 5, 2019 to December 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the catheter provided on March 26, 2020.
You asked the Plan to reduce the coinsurance for the catheter. You say that in the past you have only paid $91.80 for your equipment. 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 20% coinsurance for covered in-network prosthetic devices and supplies. You have been asked to pay $161.0 which is 20% of the allowed amount for the catheter. The allowed amount is $805.50. ($805.50 x 20% = $161.10). The catheter falls within the "Prosthetic devices and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for the catheter provided on March 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 indenying the request to pre-approve admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease,pneumonia and LA thrombus and was admitted to the hospital after a fall. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a modified independent/stand by assist to minimal assist level with functional mobility including gait to 55 feet. There are no identifiable skilled nursing service needs.  There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from February 24, 2020 to February 29, 2020.You asked the Plan to waive the copayment for these services. You say that you disagree with the charges.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 $225 copayment per day for days 1-5 for inpatient hospital care. Review of the file shows that you received inpatient hospital services from February 24, 2020 to February 29, 2020. You have been asked to pay a $225 copayment per day for days 1-5 for these services, for a total of $1,125. These services fall within the inpatient hospital 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 inpatient hospital services rendered from February 24, 2020 to February 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora Decipher Prostate Cancer Classifier Assay.You asked the Plan to pay forthe test. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this test is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per guidelines, Decipher is approved for no worse than low risk prostate cancer and a life expectancy of greater than 10 years. This member does not meet this criteria.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 test have not been met.Therefore, we decided that the Plan does not have to pay fora Decipher Prostate Cancer Classifier Assay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrollee is generally medically stable after sustaining pelvic and sacral fractures with no recent neurological events and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. Currently the enrollee is at minimal assist for all mobility. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.Based on review of the available records, the enrollee does not meet criteria for coverage for an admission to an IRF. Admission to an IRF is not medically necessary based on medical stability and functional status.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forprovision of test materials and equipment for home INRmonitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests (G0249) on December 16, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Current Procedural Terminology (CPT) code G0249 (1 Unit) for date of service December 16, 2019 remains not supported CMS Manual System Pub 100-20 One-Time Notification TN2076/CR10622: Current procedure Code G0249 is not supported on appeal as NCD 190.11 Prothrombin Time/International Normalized Ratio (PT/INR) Contractors shall delete Current Procedural Terminology (CPT) 93792, 93793 effective January 1, 2018 added to NCD in error. Contractors shall be aware of frequency edit change to Multi-Carrier System MCS) 233A effective October 1, 2018 and removal of override. MCS to change frequency in audit 233A from 29 days to 25 days, remove override, and add G0249 effective October 1, 2018.Therefore, we decided that the Plan does not have to pay forprovision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests (G0249) on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy (D3330) provided on February 24, 2020.
You asked the Plan to pay for endodontic therapy (D3330). You say that you were recommended to get a root
canal due to an infection. You say that the claim should be paid for the safety of your health. The Plan denied
your request. The Plan says the 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
endodontic therapy (D3330) provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forprogressive lens per lens (V2781), frames, purchases (V2020), Anti-reflective coating (V2750), lens polycarbonate or equal, any index, per lens (V2784), and vision supply accessory and/or service component of another vision code (V2797)provided on October 26, 2019.You asked the Plan to pay forthe eyewear. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You exhausted your maximum benefit allowance. Per your claim, $40 of the $200 allowance was applied to the coverage for the Polycarbonate (V2784), the remaining $140 was applied to the Progressive Lens -Premium Tier 4, (V2781). Payment was not made for the three (3) remaining services as the benefit limit was exhausted. Your EOC states, "there is $200 reimbursement allowance toward the purchase of eyewear. The benefit applies to corrective (prescription) glasses,lenses, frames and/or contact lenses purchased from a participating or nonparticipating provider. After the plan-paid benefits, the member is responsible for the remaining cost."Therefore, we decided that the Plan does not have to pay forprogressive lens per lens (V2781), frames, purchases (V2020), Anti-reflective coating (V2750), lens polycarbonate or equal, any index, per lens (V2784), and vision supply accessory and/or service component of another vision code (V2797) provided onOctober 26, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on March 12, 2020.You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or pre-authorized. There were network providers available.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 psychotherapy services (90832) provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on December 18, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says 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 hospital outpatient clinic visit. 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 a hospital outpatient clinic visit provided on December 18, 2019.