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

We decided that the Plan does not have to pay forthe tetanus vaccine you received on April 22, 2019.You asked the Plan to pay forthe tetanus vaccine. The Plan denied your request. The Plan says this is not covered under your medical plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the tetanus vaccine.Therefore, we decided that the Plan does not have to pay forthe tetanus vaccine you received on April 22, 2019.Benefits for the tetanus vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits andappeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99203), and removal of impacted ear wax from one ear (69210) provided on September 25, 2019.You asked the Plan to pay foran office visit, and removal of impacted ear wax. You say that you were visiting Kalispell, MT and needed to see an ear, nose and throat(an ENT) specialist. You say you did not realizethat you only had urgent care, emergency room and dialysis benefits when traveling out of the area.The Plan denied your request. The Plan says you must receive your care from a network provider. The plansays that in most cases care you receive from an out-of-network provider will not be 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 fromout-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99203), and removal of impacted ear wax from one ear (69210) provided on September 25, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), routine
venipuncture (36415), and laboratory procedures (83520, 84165, 84425, 84443, 84446) provided on July 10,
2019 by the out of network provider.
You asked the Plan to pay for a hospital outpatient clinic visit, routine venipuncture, and laboratory procedures.
You say that the patient's services were medically necessary due to limited scleroderma with numbness and
burning in the right leg. You are requesting a review of the attached records in order to reprocess the claim for
payment. The Plan denied your request. The Plan says the facility is a non-network
provider who does not work with the member's health plan, and the member was referred by a physician, who also does not work with the member's plan. The member's primary care physician did not
refer for services. The health 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 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 a hospital outpatient clinic visit (G0463), routine
venipuncture (36415), and laboratory procedures (83520, 84165, 84425, 84443, 84446) provided on July 10,
2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 31, 2019.You asked the Plan to pay for the physician's services. 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 topay 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 physician's services provided on May 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires prolonged hospitalization and close physician monitoring.The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute setting.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for multi-organ failure in the setting of alcohol abuse. The enrollee was intubated/ventilated upon admission and subsequently received a tracheotomy. The enrollee has been failing ventilator weaning trials and appears to remain acutely ill. The enrollee does not appear to be clinically appropriate for ventilator weaning at this time. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine (72148).You asked the Plan to pre-approvean MRI of the lumbar spine. You say that the service is 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 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 lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found the medical records indicate that you havelow back pain. There is no documentation of any neurological deficits on exam and no history of treatment with conservative therapies such as medication or physical therapy. MRI of the lumbar spine is recommended to evaluate for evidence of cauda equina, tumor, infection, or fracture when plain films are negative and neurologic abnormalities are present on physical exam. MRI's are test of choice for patients with prior back surgery, but for uncomplicated low back pain, with radiculopathy, not recommended until after at least one-month conservative therapy, sooner if severe or progressive neurologic deficit. Repeat MRI is not routinely recommended, and should be reserved fora significant change in symptoms and/or findings suggestive of significant pathology. The review has determined that the requested MRI is not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met.Therefore, we decided that the Plan does not have to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine (72148)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided from June 5, 2019 to June 12, 2019You asked the Plan to waive the copayment for radiation therapy. You say that you cannot afford this charge.The Plan denied your request. The Plan says these services processed 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 therapeutic radiology services. You have been asked to pay $1,160.49 ($5,802.45 allowed amount x 20% = $1,160.49) for radiation therapy. 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 radiation therapy provided from June 5, 2019 to June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for CPAP supplies provided on September 4, 2019.You asked the Plan to waive the coinsurance for the CPAP supplies. 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 CPAP supplies provided on September 4, 2019. You are asked to pay20% coinsurance for the DME. 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 CPAP supplies provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 12, 2018
to September 27, 2018 by the out of network provider.
You asked the Plan to pay for the out-of-network services. You say that the enrollee was seen by an out-of-network
provider in error. The Plan denied your request. The Plan says services provided by non-participating
providers are excluded.
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 services at
issue. We found no exception that would require the Plan to pay for these out-of-network services. Therefore,
we decided that the Plan does not have to pay for the medical services provided to the enrollee on July 12, 2018 to
September 27, 2018 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on September 19, 2019 by out of network provider, the doctor" You asked the Plan to pay foran office visit. You say that you are appealing claim payment denial for services rendered to the Plan's member on date of service September 19, 2019. You also say that you have included notes that support the need for service.The Plan denied your request. The Plan says the rendering provider, "the doctor", is a non-participating provider. The Plan says it did not authorize any services for "the health system" or "the doctor". The Plan further says there are multiple in network providerswithin 30 miles of the members residence that could have rendered the services. The services were not considered urgent/emergent in nature.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay foran office visit (99214) provided on September 19, 2019 by out of network provider, "the doctor".
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve31 units (26 hours) of neuropsychological testing.You asked the Plan to pre-approveneuropsychological testing. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is allowed five units without authorization and the documentation does not show that additional testing time is needed to assess the origin of the enrollee's symptoms or come up with a treatment plan.The Plan follows Medicare rules. Medicare rules say that supporting documentation in the medical record must be present to justify greater than 8 hours of neuropsychological testing per patient per evaluation.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 neuropsychological testing. Our reviewer says that the available documentation does not support that 31 units (26 hours) of neuropsychological testing is medically necessary to diagnoseand characterize the neurocognitive effects of medical disorders that impinge directly or indirectly on the brain in this case. Our physician reviewer found the plan has approved 5 units of neuropsychological testing, which is approximately 4.2 hours. Thedocumentation does not support that additional testing is 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 neuropsychological testing have not been met.Therefore, we decided that the Plan does not have to pre-approve31 units (26 hours) of neuropsychological testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital discharge day management; more than 30 minutes (CPT Code 99239)provided to the enrollee on April 19, 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 Medicare rules have not been met.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. Medical records dated April 17, 2019 state the member is ready for discharge and denied any suicidal ideation, homicidal ideation, or psychosis. However, additional medical records from April 17, 2019 state the patient was unable to be discharged as she was unable to make it on time to the Rope Center. Per the LCD, psychiatric inpatient hospitalization coverage is excluded for services which are primarily custodial; services attempting to maintain psychiatric wellness for the chronically mentally ill; and treatment of chronic conditions without acute exacerbation or the ability to improve functioning.Therefore, we decided that the Plan does not have to pay forhospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on April 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on June 14, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that this should be covered in full.The Plan denied your request. The Plan says that 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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on June 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora home visit for the evaluation and management of an established patient (99348) provided on June 13, 2019 by out of network provider.You asked the Plan to pay fora home visit. You say that you want this denied service reviewed.The Plan denied your request. The Plan saysthe provider is a non-network provider who does not work with the member's health plan, and the member was referred by the physician, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health 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 has network providers available who can provide the items/services at issue inthis appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora home visit for the evaluation and management of an established patient (99348) provided on June 13, 2019 by out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forphysical therapy provided from July 9, 2019 through July 30, 2019. You asked the Plan to waive the copayments forphysical therapy. You say that you have never had a copayment for a physical therapy session. You say that you do not feel you owe a 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 $10 copayment for each Medicare-covered outpatient rehabilitation service visit.You have been asked to pay a $10 copayment for each physical therapy visit. The total amount you owe is $40 ($10/visit x 4 visits = $40). Physical therapy falls within the "Outpatient rehabilitation services" 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 copayments forphysical therapy provided from July 9, 2019 through July 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require the intense level of therapies provided in an acute rehab facility.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 physician reviewer found that the enrollee is at minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The complexity of the enrollee's  nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).You asked the Plan to pre-approve a CT scan of the chest. You say that this is medically necessary.The Plan denied your request. The Plan says there are no other abnormal labs or test results necessitating a CT.The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan of the chest. Our reviewer says that coverage criteria for a repeat chest CT have not been not met. Our physician reviewer found the enrollee has known tiny (3 mm) pulmonary nodules that were stable on a low-dose chest CT in 2018. A CT report from July 4, 2019 indicates nodules, but there is no comparison with previous CTs, and no indication of nodule size. Therefore the necessity of a repeat chest CT is not established. It is necessary to know the size of the nodules, and whether they have changed from the previous CT, in order to determine the appropriate follow-up. Without this information, the repeat chest CT is considered 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 a CT scan of the chest have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the chest (71250).