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

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from March 18, 2021, to March 29, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the charges because your condition was due to having the coronavirus. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $310 copayment for days 1-7 for inpatient hospital care. 

You received inpatient hospital care from March 18, 2021, to March 29, 2021. Therefore, you are responsible to pay a $310 copayment for days 1-7 (March 18, 2021, to March 24, 2021). The total amount you owe is: $310 (copayment) x 7 (inpatient days) = $2,170. 

You have been asked to pay the total copayment amount of $2,170 for inpatient hospital care. Inpatient hospital care falls 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 inpatient hospital care provided from March 18, 2021, to March 29, 2021.
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 requested admission to an IRF does not meet
criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 does not need intensive therapies, consisting of at least 3 hours of
therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee
may benefit from physical therapy, and occupational therapy, her rehab needs can be safely provided in an
alternate and low intensity setting such as in a skilled nursing facility.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stress Echocardiogram and Event Monitoring (CPT Code(s): 93351 and 0296T) to be performed by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services requested are for diagnostic purposes and are not noted by the physician to be necessary to determine urgent or emergent care or treatment. The Plan states these services can be provided within enrollee's provider network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. Therefore, we decided that the Plan does not have to pre-approve Stress Echocardiogram and Event Monitoring (CPT Code(s): 93351 and 0296T) to be performed by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the transnasal esophagoscopy (43197) provided on July 8, 
2021.

You asked the Plan to pay for the transnasal esophagoscopy (43197). You say that the transnasal and transoral 
esophagoscopy were performed during separate encounters. You say that payment should be reconsidered 
based on medical necessity as the first attempt to clear the patient's airway was unsuccessful. The Plan denied 
your request. The Plan says there are no modifiers allowed with this code pair.

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, we have confirmed that code 43197 
is a column II code to column I code 43220. This claim cannot be billed with a modifier to bypass the edit. 
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan 
does not have to pay for the transnasal esophagoscopy (43197) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on September 23, 2021.

You asked the Plan to waive the copayment for an office visit. You say that you went in for a coronavirus test and do not understand why you are being charged. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for primary care provider visits. 

You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bedside drainage bag (A4357) Ostomy pouch (A4430) provided on October 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the Ostomy supplies. You say that you have been getting Ostomy supplies from this provider for a long time and you were never made aware that they would not be in the network for your new plan. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 bedside drainage bag (A4357) Ostomy pouch (A4430) provided on October 19, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for x-rays provided on April 22, 2021.

You asked the Plan to waive the deductible for x-rays. You say that the x-rays were taken to the check your
progress after having the coronavirus. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is a $750 deductible which applies to outpatient hospital services.

You received x-rays on April 22, 2021. The record shows that you had only paid $352.97 toward the $750
deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of
$88.67.

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient
hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible which applies to x-rays. This cost sharing is a contractual obligation that had not been met at the
time x-rays were received on April 22, 2021. Therefore, we decided that the Plan does not have to waive the
deductible for x-rays provided on April 22, 2021.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure and respiratory failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda (J9271). You say that the service is medically necessary. The Plan denied your request. The Plan says the drug is not being used for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Keytruda (J9271). Our reviewer says that the service is not medically necessary. Our physician reviewer found the item is not FDA-approved for the enrollee's diagnosis and the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda (J9271) have not been met. Specifically, the item requested is not medically necessary as it is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit services (99349) provided on August 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit. You say that please process all claims attached on basis of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 established patient home visit services (99349) provided on August 6, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on June 2, 2021, from an out-of-network provider.
You asked the Plan to pay for the hearing aids. You say that these services are necessary, and this provider offered them to you at a better cost. The Plan denied your request. The Plan says these hearing aids were purchased from a provider who is outside the Plan's specified routine hearing vendor network. Hearing aids must be purchased through the specified network in order to be eligible for coverage or reimbursement.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased through the Plan's specified hearing vendor. We looked at this the file and the Plan's rules. The provider in this case is not part of the Plan's specified routine hearing network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) purchased on June 2, 2021, from an out-of-network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for refractory hypomagnesemia for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is the best place for the testing to be done. The Plan denied your request. The Plan says the requested laboratory is out-of-network.
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 pre-approve the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is reported to have severe, refractory hypomagnesemia. No documentation of relevant abnormal labs, related symptoms, prior evaluation, failed treatment or a working differential are noted. As such, the documentation does not support that the requested genetic testing is medically necessary and reasonable to diagnose, treat or manage the enrollee's condition. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for refractory hypomagnesemia for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 10, 2021.

You asked the Plan to pay for the panoramic x-ray. You say that you were advised that you had one free oral exam and a free teeth cleaning, very basic coverage. You also say that after you had x-rays taken you were advised that the deep cleaning they wanted to provide was not covered, and your teeth were not cleaned. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on September 10, 2021.

Your complaint about the provider taking a second set of x-rays is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on September 21, 2021.

You asked the Plan to pay for the testing services. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says separate charges are not eligible for payment.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

In this case, CPT code 70544 was billed with code 70551. We find that CPT code 70544 may be eligible for payment when billed with this code pair. The claim information does not show that the code at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) provided on September 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says based on the Medicare guidelines and information about the enrollee's condition, the enrollee does not meet the requirements for coverage.
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 that 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. The enrollee was admitted for seizure. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's records show that it is not reasonable to expect that the enrollee will be able to safely actively participate in, nor fully benefit from, the intensity of services of an IRF.
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. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. The enrollee's care needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.