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

 We decided that the Plan does not have to pay for the laboratory services provided on February 10, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  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 laboratory services provided on  February 10, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided from August 11, 2020, through August 14, 2020 with the reported secondary diagnosis, E87.2, Acidosis.  You asked the Plan to pay for inpatient services provided with the reported secondary diagnosis, E87.2, Acidosis. The Plan denied your request. The Plan says while the physician also indicated a diagnosis of lactic acidosis, and the patient was treated with intravenous fluids, the highest lactic acid level was 3.0 and there was no blood gas found for review.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with the secondary diagnosis, E87.2, Acidosis. 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 services with the reported secondary diagnosis, E87.2, Acidosis. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that although, Lactic Acidosis is documented throughout hospital stay, and intravenous (IV) therapy was given, the documentation does not support the clinical requirements required by the healthcare Plan to confirm a secondary diagnosis of metabolic acidosis. In this case, the documentation for lactic acid includes "Elevated lactic acid likely secondary to dehydration" and IV therapy was given, the documentation does not support lactic acid >4.  The documentation does not include arterial blood gases performed, and therefore does not meet validation criteria per healthcare Plan guidelines.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from August 11, 2020, through August 14, 2020 with the reported secondary diagnosis, E87.2, Acidosis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from June 29, 2020, through
July 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
You asked the Plan to pay for inpatient services with the reported principal diagnosis A41.9, sepsis, unspecified organism. The Plan denied your request. The Plan says although the provider documented sepsis, reasonable support within the health record must be present for that diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with the principal diagnosis A41.9, sepsis, unspecified organism. 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 services provided from June 29, 2020, through July 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation supported an admission for pneumonia. The enrollee was a then, 86 year old female with a history of chronic kidney disease (CKD) who presented to the emergency department (ED) on June 29, 2020 with shortness of breath. Her initial vital signs revealed her blood pressure was 173/82, RR 61 with a heart rate of 125 and her oxygen saturation was 87% on 6 liters of oxygen. Her creatinine was 1.4 and her initial lactate was 2.22; chest X-ray revealed bilateral multifocal opacities. She was started on Intravenous (IV) antibiotics. She was alert and oriented throughout the hospitalization. There were no clinical or laboratory signs of sepsis. The review has determined that the principal diagnosis A41.9, Sepsis, unspecified organism, was not supported by the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from June 29, 2020, through July 9, 2020 with the reported principal diagnosis A41.9, sepsis, unspecified organism.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to
the enrollee on May 24, 2021.
You asked the Plan to pay for the service. You say that this should be covered based on this service being
covered by Medicare. The Plan denied your request. The Plan says the service is not supported by the records.
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 service have not been met. The algorithms employed in
combinatorial testing is also not currently considered reasonable and necessary components of multi-gene
testing. In addition, there is no Z code provided as required per A58324. Also, the order is not signed.
Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479)
provided to the enrollee on May 24, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services.  You asked the Plan to pre-approve skilled nursing facility services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable daily skilled nursing or skilled therapy needs that are needed on an inpatient basis. You do not meet the 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided January 29, 2021 to  February 2, 2021.  You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with I50.33 defined as acute on chronic diastolic (congestive) heart failure. 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 inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the Cardiology consultant noted the enrollee had a history of congestive heart failure, but this was not a diagnosis in the past medical history. On cardiac catheterization the enrollee's pressures were normal and the chest CT demonstrated changes consistent with chronic interstitial lung disease. The enrollee's lung exam was consistently reported as clear. The documentation shows that the secondary diagnosis I50.33, Acute on chronic diastolic (congestive) heart failure was not supported by the documentation. Therefore, the DRG billed is not supported by the documentation.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided January 29, 2021 to February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services provided  January 6, 2021 to January 14, 2021.  You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that the inpatient services are not supported in the medical record. Specifically, diagnosis code Z86.16 (Personal history of Coronavirus ((COVID-19)) is present on exempt code but present on admission is listed for these codes is "Y". These codes need to be blank; we find the Medicare rule for payment of this January 06, 2021 through January 14, 2021, claim has not been met.  Based on this information, we decided that Medicare rules for coverage of the inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient services provided  January 6, 2021 to January 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 9, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, the physician must clearly document, in the medical record, his or her intent that the test be
performed.
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided
that the Plan does not have to pay for the laboratory services provided on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Tyvaso solution.  You asked the Plan to pre-approve Tyvaso solution. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tyvaso solution.      Benefits for Tyvaso solution may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist's office visits provided from January 22, 2021 to April 2, 2021.
You asked the Plan to waive the copayment for the specialist's office visits. You say that you are struggling to pay these bills. You say they should be waived since it is due to having COVID. 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 a $40 copayment for each specialist's office visit. You have been asked to pay a $40 copayment for each specialist's office visit. The specialist's office visits fall 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 the specialist's office visits provided from January 22, 2021 to April 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmic ultrasound, diagnostic;
corneal pachymetry, unilateral or bilateral (76514) provided on August 6, 2021.
You asked the Plan to waive the copayment for an ophthalmic ultrasound, diagnostic; corneal pachymetry,
unilateral or bilateral. The Plan denied your request. The Plan says the allowable for the service is less than the
$20 ultrasound copayment, you are being asked to pay the lesser 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 $20
copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay the lesser amount of a $20 copayment for an ophthalmic ultrasound, diagnostic;
corneal pachymetry, unilateral or bilateral. An ophthalmic ultrasound, diagnostic; corneal pachymetry,
unilateral or bilateral falls within the outpatient diagnostic tests and therapeutic services and 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 waive the copayment for an ophthalmic ultrasound, diagnostic; corneal
pachymetry, unilateral or bilateral (76514) provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist physician visits provided from
May 21, 2021, to May 27, 2021.
You asked the Plan to waive the copayment for the specialist physician visits. You say that you were charged
for physical therapy during your inpatient stay. You say that you should not have to pay these copayments. 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 a $20
copayment for each outpatient specialist physician visit.
There is no evidence in the file showing you were admitted to the hospital under inpatient status. The record
does not show that you were charged for physical therapy. The charges you appealed were for physician
services. You have been asked to pay a $20 copayment for each specialist physician visit. Specialist physician
visits falls within the Outpatient Hospital 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
copayment for specialist physician visits provided from May 21, 2021, to May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486-59, 87496-59, 87498-59, 87532-59, 87541-59, 87581-59, 87640-59 and 87798-59) provided to the enrollee on September 14, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 laboratory services have not been met. CPT code(s): 87486-59, 87496-59, 87498-59, 87532-59, 87541-59, 87581-59, 87640-59 and 87798-59 remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in an office, POS 11; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Nursing facility POS 32. Also, the laboratory results submitted indicate the specimen was collected on September 14, 2020, and received by the lab on September 15, 2020. Of note, the enrollee resides in Missouri (MO) and the billing laboratory is in Arizona (AZ); therefore, the billed code cannot be verified. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87486-59, 87496-59, 87498-59, 87532-59, 87541-59, 87581-59, 87640-59 and 87798-59) provided to the enrollee on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided from February 25, 2021, through April 1, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 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). The procedure was performed in a licensed accredited outpatient facility of a major medical center. This copay is for use of the facility and the equipment for your procedure, not for the doctor's services. You received the outpatient hospital services for three (3) dates of service, February 25, 2021, March 4, 2021, and April 1, 2021.
You were asked to pay a $150 copayment for each date of service for the outpatient hospital services. Your 2021 EOC says that enrollees must pay a $150 copayment for each visit to an outpatient hospital facility. 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 pay for the outpatient hospital services provided from February 25, 2021, through April 1, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 office visit provided on March 5, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from September 3, 2020 to September 5, 2020 and billed under diagnosis related group (DRG) code of A41.9.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. 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 these services. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found there was no evidence of a systemic, life-threatening organ dysfunction due to a dysregulated host response to infection, defining sepsis. The enrollee did not suffer with significant hypotension or signs of end organ hypoperfusion. Her white blood cell count was noted to be elevated but there was no evidence of a dysregulated host response to infection. Platelets, creatinine, and total bilirubin values were within normal limits. The review has determined that the documentation did not support the billed principal diagnosis code A41.9 defined as Sepsis, unspecified organism. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the enrollee from September 3, 2020 to September 5, 2020 and billed under diagnosis related group (DRG) code of A41.9.