Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided January 8, 2020 to
January 11, 2020.
You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary for the enrollee. The Plan denied your request. The Plan says that the case file was forwarded to an independent review organization because a decision was not provided within sixty calendar days after receiving your appeal.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on January 8, 2020 after an unwitnessed fall with mental status changes. Evaluation revealed he was intoxicated. The computed tomography scan (CT) of the facial bones revealed a nasal fracture, the CT scan of the cervical spine was normal. The enrollee was evaluated and treated with IV fluids and was then admitted. He was observed for potential alcohol withdrawal. His condition stabilized and improved, and he was discharged home on January 11, 2020 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided January 8, 2020 to January 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe nerveconduction studies provided on October 4, 2019.You asked the Plan to waive the copayment forthe nerve conduction studies. You say that you were not advised of a diagnostic test that required you to pay $150. You say that you only expected to pay the $30 copayment.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for all other diagnostic procedures and tests. A separate PCP/Specialist cost-share will apply if additional services requiring cost-sharing are rendered.You have been asked to pay a $150 copayment for the nerve conduction studies. The nerve conduction studies fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.Outpatient diagnostic tests are considered a separate service. 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 forthe nerve conduction studies provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the portable gaseous oxygen system and
oxygen concentrator rendered on January 19, 2019 to November 19, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you are being charged more
because the contract changed. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a 20% coinsurance for durable medical equipment and related supplies.
Review of the file shows that you received a portable gaseous oxygen system and oxygen concentrator from
January 19, 2019 to November 19, 2019. The enrollee has been asked to pay a 20% coinsurance for these
services. These services fall within the durable medical equipment and related supplies benefit category. This
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided
that the Plan does not have to waive the coinsurance for the portable gaseous oxygen system and oxygen
concentrator rendered on January 19, 2019 to November 19, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the cervical spine (72141).
You asked the Plan to pre-approve an MRI of the cervical spine. You say that the requested MRI of the cervical spine is medically necessary. The Plan denied your request. The Plan says that the requested MRI of the cervical spine is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the cervical spine. Our reviewer says that the requested MRI of the cervical spine is medically necessary. Our physician reviewer found in this case the member is noted to have acute onset of left arm numbness with some radiation (of numbness/discomfort) up the forearm. At the same time, he reports neck pain. The differential diagnoses in this case include a radicular process versus a local or compressive neuropathy. An imaging study would generally be appropriate to help reach a diagnosis. We looked at this physician's review, the file, and Medicare rules. The Plan confirmed with the provider's office that the enrollee's implanted device is MRI compatible. Based on this information, we decided that Medicare rules for coverage of an MRI of the cervical spine have been met. Therefore, we decided that the Plan has to pre-approve an MRI of the cervical spine (72141).
If the Plan does 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/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided at the in-network benefit level by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visits. You say that you have been seeing this physician for more than 10 years and it would be difficult to develop a relationship with a new physician. The Plan denied your request. The Plan says the denial of authorization for these services at the in-network benefit level is correct, because this provider is out-of-network with the Plan. The Plan also says that they have authorized a 60-day transition period for you to locate an in-network provider, after which point you will have to use your out-of-network visits to see the requested provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you can choose to see out-of-network providers, however your cost-share for out-of-network covered services may be different from the in-network benefit level. 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 at the in-network benefit level. The Plan has approved a 60-day transition period, after which you can continue seeing this provider at the out-of-network benefit level. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided at the in-network benefit level by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to preapprove a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from skull to thigh (78815).
You asked the Plan to preapprove a PET CT scan from skull to thigh. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 a PET CT scan from skull to thigh. Our reviewer says that the services are medically necessary. Our physician reviewer found while CMS guidelines customarily require a positive cytological result for malignancy in order to qualify for PET/CT (not the case here) the guidelines also state that 1 PET/CT scan may be obtained when there is strong suspicion of malignancy and treatment options may be optimized via results of the scan. In this particular case the possibility of malignancy, especially lymphoma is overwhelmingly high. The enrollee has no symptoms of infection and there is obstructive uropathy of the left kidney. It is also inevitable that once a malignant diagnosis has been secured via biopsy PET/CT will be necessary. For these reasons, PET/CT would be in the best interest of the enrollee and the criteria for a single PET/CT scan have been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET CT scan from skull to thigh have been met. Therefore, we decided that the Plan has to preapprove a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from skull to thigh (78815).
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 services are medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe facet joint injection provided on February 3, 2020.You asked the Plan to waive the copayment forthe facet joint injection. You say that you don't agree with the billed code. You say that you don't think the injections are considered surgery.The Plan deniedyour request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each visit for Medicare-covered outpatient surgery performed in a hospital or ambulatory surgical center. You have been asked to pay a $250 copayment for the facet joint injection. The facet joint injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The facet joint injection is considered a surgical injection. 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 forthe facet joint injection provided on February 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordeluxe frames (V2025) single vision lenses (V2100) lenses (V2783) anti-reflective coating (V2750) UV lenses (V2755) provided March 5, 2020.You asked the Plan to waive the copayment forthe vision services. You say that you're just out until next year with a $303 bill. Until this time all the glasses you got were inside the amount the insurance would pay. You did not take the glasses as they are useless.The Plan denied your request. The Plan says the eyewear benefit has been exhausted and the correct cost-share was applied per the plan 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). Your contract with the Plan clearly says that you must pay any amount over the $200 eyewear benefit.  You have been asked to pay $303 for the vision services. The provider billed a total of $579.96. The plan paid $275.99 leaving a balance of $303.97.  The vision services fall within the Vision 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 fordeluxe frames (V2025) single vision lenses (V2100) lenses (V2783) anti-reflective coating (V2750) UV lenses (V2755) provided March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on January 30, 2020.You asked the Plan to waive the copayment forthe officevisit. You say that you should not have to pay for a specialist when you saw a physician assistant.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per specialist office visit. You have been asked to pay a $20 copayment for the office visit.The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were seen in an orthopedics office, which is considered a specialist office. 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 forthe office visit provided on January 30, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested 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 the requested IRF admission. Our physician reviewer found the enrollee is with a past medical history of coronary artery disease, congestive heart failure and hypothyroidism who is in his home. He has experienced increased weakness and unstable gait for the past few weeks. The provided records do not indicate that he has been evaluated in a hospital or with a medical provider for these acute symptoms. He is walking with a walker and is minimum to moderate assist for transfers and activities of daily living. He is not on supplemental oxygen and has no reported wounds. He has had falls, his balance is poor - his last fall was on 06/09/2020. The etiology of his decline is unclear - the provided records do not document any evaluation or work-up of his recent symptoms. Further evaluation of his condition with his primary care provider appears to be more appropriate in this case. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee requires more evaluation before an intensive inpatient rehabilitation therapy program would be recommended. Based on the medical records provided the etiology of his decline is unclear. Further evaluation of his condition with his primary care provider appears to be more appropriate in this case.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemodenervation provided on
February 18, 2020.
You asked the Plan to waive the copayment for the chemodenervation. You say that this was done in the
neurology clinic by the doctor. You say that you shouldn't have to pay any other copayment. The Plan denied
your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for all other outpatient services not provided in an ambulatory surgical center.
You have been asked to pay a $300 copayment for the chemodenervation. The chemodenervation falls within
the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The records show that the chemodenervation was also billed by the hospital. 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 chemodenervation provided on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (CPT 87631) provided on February 20, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this service is not covered for this diagnosis.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services (CPT 87631) provided on February 20, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
You asked the Plan to pre-approve the compression stockings. You say that the requested items 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. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
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 an oxygenator or
heat exchanger (99190) provided on August 15, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this was a mandatory 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 an oxygenator or heat exchanger
(99190) provided on August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone density scan (77080) provided on February 5, 2020.You asked the Plan to pay forthe bone density scan. You say that the services were medically necessary.The Plan denied your request. The Plan says the scan was 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 forthe bone density scan (77080) provided on February 5, 2020.