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

We decided that the Plan does not have to pay for post stabilization services provided after January 27, 2019.
You asked the Plan to pay for the post stabilization services after January 27, 2019. You say that the inpatient
services were medically necessary. The Plan denied your request. The Plan says after January 27, 2019, the
enrollee was stable for transfer to Plan hospital facility.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post-stabilization services. Our reviewer
says that as of January 27, 2019, the enrollee was hemodynamically stable and appropriate for ambulance
transport with monitoring to a Plan facility for continued inpatient level of care services. Our physician
reviewer found there was no documentation provided necessitating post-stabilization care services January 27,
2019, to April 4, 2019, at the non-Plan facility. The post-stabilization care services were not medically
necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an
order) that the patient was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for post-stabilization services provided after January 27, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) provided on October 29, 2020.
You asked the Plan to waive the copayment for MRI. You say that the provider should have warned you about this copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $200 copayment for MRI at an outpatient hospital. You have been asked to pay $200 copayment for MRI. MRI 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 Magnetic Resonance Imaging (MRI) provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
You asked the Plan to pay for lumbar-sacral orthosis. You say that the item was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw the enrollee.
The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when the criteria in the Medicare rules section is met. 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 lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is
insufficient documentation of a credible evaluation and a credible physical examination of the back. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for crisis intervention service, per 15 minutes (H2011) provided June 27, 2020.
You asked the Plan to pay for crisis intervention service. You say that the place of service code was assigned by the rendering clinician to report the location where the service was rendered, which cannot be changed or altered. The Plan denied your request. The Plan says this code is invalid for Medicare billing purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code H2011 is Crisis intervention service, per 15 minutes. We find that CPT code H2011 is not supported in the medical record. Specifically, code H2011 carries a Medicare Physician Status Indicator Code "I" designating Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of crisis intervention service have not been met. Therefore, we decided that the Plan does not have to pay for crisis intervention service, per 15 minutes (H2011) provided June 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 8, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these services.
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 physician services provided on October 8, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for Prostate cancer screening (G0103).

You asked the Plan to pay for Prostate cancer screening. You say that you are appealing the denial of payment
and you do not understand why some drug claims and lab tests are not paid. The Plan denied your request. The
Plan says this service exceeds the benefit frequency limitation.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

Prostate cancer screening tests is covered once every 12 months. The records show that the service was already
provided; therefore, the benefit has been exhausted. Therefore, we decided that the Plan does not have to pay 
for Prostate cancer screening (G0103).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance services (A0428 and A0425)
provided on October 22, 2020.
You asked the Plan to pay for the non-emergent ambulance services. You say that you would like
reconsideration because transportation to a physician's office is covered per COVID guidelines. The Plan
denied your request. The Plan says ambulance services to a physician's office are not a covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 non-emergent ambulance services. Our
reviewer says that the documentation does not show that other means of transportation such as stretcher van
would be contraindicated on that day. Our physician reviewer found the documentation did not show that the
member required expertise or special equipment during transportation.
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 non-emergent ambulance services have not been met. Therefore, we decided
that the Plan does not have to pay for non-emergent ambulance services (A0428 and A0425) provided on
October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the complete ultrasound examination of the retroperitoneum (76770) provided October 9, 2020.
You asked the Plan to waive the copayment for the ultrasound. You say that you have called customer service twice and have been told there would be follow up with no response. The plan shows that you should have $0 copay. Please resolve and advise why not covered. The Plan denied your request. The Plan says the claim was processed, and the correct copayment was applied per the Evidence of Coverage.
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 $105 copayment for each Medicare covered radiological diagnostic service, not including x-rays. You have been asked to pay $88.39 copayment for the ultrasound. The allowed amount of $88.39 is less than the copayment amount of $105. You are responsible for the lesser amount. the ultrasound 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 the complete ultrasound examination of the retroperitoneum (76770) provided October 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on September 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until November 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 30, 2020 and October 31, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 October 30, 2020 and October 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan.

You asked the Plan to waive the copayment for a CT scan. You say that your doctor says you need a CT scan every three months and you cannot afford this charge. The Plan denied your request. The Plan says this 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 $250 copayment for CT scans.

You have been asked to pay a $193.02 copayment for a CT scan because the allowed amount is less than $250. 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 a computed tomography (CT) scan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 17, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important to know which providers are part of our network because, with limited exceptions, while the enrollee is a member of our Plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the Plan network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 November 17, 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. the documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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 coinsurance for dialysis services (90999) provided February 13, 2020 to February 29, 2020.
You asked the Plan to waive the coinsurance for the dialysis services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for outpatient dialysis. You have been asked to pay a 20% coinsurance for the dialysis services. The dialysis services fall within the outpatient dialysis 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 coinsurance for dialysis services (90999) provided February 13, 2020 to February 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
You asked the Plan to pre-approve the power seat elevation system. You say that you would like reconsideration because you are unable to get on the bed, shower, bathroom and you cannot go without this elevator. The Plan denied your request. The Plan says Medicare criteria for wheelchair add-ons does not cover this system.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare does not cover power seat elevation systems because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the B-12 injection provided on November 13, 2020.
You asked the Plan to the B-12 injection. You say that you have never been charged before. The Plan denied your request. The Plan says you were charged the copayment 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the B-12 injection. The B-12 injection falls within the Medicare Part B prescription drugs 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 B-12 injection provided on November 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pomalyst 4 mg capsule.
You asked the Plan to pre-approve Pomalyst. You say that this request is medically necessary. The Plan denied
your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical
benefit.
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 Pomalyst 4 mg capsule.
Benefits for Pomalyst 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from September 14, 2020, to September 16, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs should be covered. The Plan denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
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 pay for the self-administered drugs provided in an outpatient setting from September 14, 2020, to September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill.
You asked the Plan to pre-approve Special Supplemental Benefits for the Chronically Ill. You say that you were told that you qualify for these benefits. The Plan denied your request. The Plan says that you do not meet criteria for these services.
The Plan must follow Medicare rules. Plan rules say that if you have been diagnosed by a qualified provider with certain chronic conditions and you meet certain criteria, you may be eligible for additional benefits. We looked at the file and Plan rules. The EOC provides a list of 15 medical conditions for which these benefits are covered. Your physician attested that you do not have any of those conditions. Based on this information, we decided that Plan rules for coverage of Special Supplemental Benefits for the Chronically Ill have not been met. Therefore, we decided that the Plan does not have to pre-approve Special Supplemental Benefits for the Chronically Ill.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) provided on October 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON office visit. You say that this is supported by the records. The Plan denied your request. The Plan says this was not authorized.
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 an office visit (99203) provided on October 13, 2020 by an out of network (OON) provider.