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

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head or brain (70450) provided October 24, 2019.
You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says this is a duplicate claim.
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 CPT code 70450 is not supported in the medical record. Specifically, the record supports that only one CT scan was performed on the date of service. A claim for payment for a CT scan has already been processed by the plan. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head or brain (70450) provided October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on February 18, 2020.
You asked the Plan to waive the copayment for these services. You say that the physician was in-network when you called the Plan in January. The Plan denied your request. The Plan says 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 $60 copayment for out-of-network specialist's office services.
Review of the file shows that you received specialist services on February 18, 2020. You have been asked to pay a $60 copayment for these services. These services fall within the out-of-network specialist's office 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. The Plan reviewed your call log from January and did not find evidence that you were informed that the provider was in-network. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on February 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 6, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
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 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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on January 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is generally medically stable and has no evidence of complex medical issues that require acute rehab nursing care, or monitoring by an inpatient physical medicine and rehabilitation (PMR) physician three times per week. While the enrollee is likely to benefit from continuing physical therapy (PT) and occupational therapy (OT), the documentation does not support that there is need for an intensive therapy program with therapy 3 hours per day, with frequent physician oversight and 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthopedic surgeon referral to an out of network
(OON) provider.
You asked the Plan to pre-approve an orthopedic surgeon referral to an OON provider. You say that you have
already seen numerous in-network physicians and they have been unable to help you. The Plan denied your
request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage
criteria has not been met.
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
an orthopedic surgeon referral to an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are 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. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, skin and nutritional care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly maximum assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or participate in an IRF 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an echocardiogram (93306) provided February 11, 2020. 
 
You asked the Plan to waive the coinsurance for the echocardiogram. You say that the coinsurance 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 diagnostic procedures.  
 
You have been asked to pay a 20% coinsurance for the echocardiogram. The echocardiogram falls within the diagnostic procedures 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 an echocardiogram (93306) provided February 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography (CT) of the Chest
(71250) provided January 13, 2020.
You asked the Plan to waive the copayment for the CT scan. 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 $250
copayment for Diagnostic Radiology.
You have been asked to pay the allowed amount of $137.94 for the CT scan. This is less than the $250
copayment stipulated in the plan contract. the CT scan falls within the Diagnostic Radiology 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 Computed Tomography (CT) of the Chest (71250) provided
January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist office visit, the injection, and
the x-ray provided on January 17, 2020.
You asked the Plan to waive the coinsurance for the specialist office visit, the injection and the x-ray. You say
that you paid $250 up front for the services and you do not feel that the $205.76 reimbursement is fair. 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 30%
coinsurance for Point of Service (POS) coverage.
You have been asked to pay a total of $88.19 for the specialist office visit, the injection and the x-ray. The
specialist office visit, the injection and the x-ray falls within the "Point of Service (POS) coverage" 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 the specialist office visit, the injection, and the x-ray
provided on January 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyz Hcl Tab 10mg.
You asked the Plan to pre-approve Hydroxyz Hcl Tab 10mg. You say that the medication is necessary. The
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for
coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Hydroxyz Hcl Tab 10mg.
Benefits for Hydroxyz Hcl Tab 10mg 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for bifocal lenses (V2200) provided January 24, 2020. 
 
You asked the Plan to pay for the lenses. You say that due to a lot of problems, you had to make an appointment. You did not realize it was before the 2 years. Due to the fact the lens exam was 10 days before the 2 years you request reconsideration. The Plan denied your request. The Plan says this request exceeds the frequency limitations. 
 
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. This benefit is allowed once every 2 years. The records show this benefit was approved February 8, 2018. 
 
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 bifocal lenses (V2200) provided January 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the cataract surgery provided on April 16,
2019.
You asked the Plan to waive the deductible for the cataract surgery. You say that you were told your deductible
was $350 total and you cannot pay this amount. 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. Your
contract with the Plan says that there is a $1,000 deductible that applies towards outpatient surgery at an innetwork
outpatient hospital.
The cataract surgery you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $1,000 deductible that applies towards outpatient surgery at an innetwork
outpatient hospital. This cost sharing is a contractual obligation that had not been met at the time the
cataract surgery was received on April 16, 2019. Therefore, we decided that the Plan does not have to waive
the deductible for the cataract surgery provided on April 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for extraction of erupted tooth teeth 02, 6, 11,
12, 13 (D7140x5) provided February 13, 2020.
You asked the Plan to waive the coinsurance for the dental services. You say that you are appealing the dental
claim and requesting payment for the remainder $212 on the dental extractions. You also need a complete
upper dentures request coverage for the costs of both. The Plan denied your request. The Plan says the copay
was applied correctly per the plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50%
coinsurance for dental extractions.
You have been asked to pay $212.50 for the dental services. The services fall within the dental 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 coinsurance for extraction of erupted tooth teeth 02, 6, 11, 12,
13 (D7140x5) provided February 13, 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 IRF admission is medically necessary. The Plan
denied your request. The Plan says the IRF services do not meet the above criteria of medical necessity.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee is medically stable and does not have complex medical issues that
require acute rehab nursing care or monitoring by an inpatient rehabilitation physician three times per week.
While he may well benefit from continuing physical therapy, there is no evidence of need for an intensive
therapy program with therapy 3 hours per day with frequent physician oversight and 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-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 cost share for the intravitreal injection and ranibizumab
injection provided on January 30, 2020.
You asked the Plan to waive the cost share for the intravitreal injection and ranibizumab injection. You say that
drugs are covered if billed in conjunction with an office visit. You say that you should be reimbursed. The Plan
denied your request. The Plan says the cost share applied correctly.
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 your combined in-network and out-of-network medical deductible is $51. Your
contract with the Plan says that there is 10% coinsurance for Medicare-covered surgery or other services at an
in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other
facility charges and physician or surgical charges. Your contract with the Plan says that there is no coinsurance
or copayment for each Medicare-covered Part B drug and the administration or infusion of that drug if billed in
conjunction with an office visit copay or 20% if not billed in conjunction with an office visit copayment at an
in-network provider.
The intravitreal injection you asked the Plan to waive the deductible for falls within the "Outpatient Surgery
and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $51
deductible applies to outpatient surgical services. This cost sharing is a contractual obligation that had not been
met at the time the intravitreal injection was received on January 30, 2020. Therefore $51 has been applied to
meet your deductible.
Since your $51 deductible was met, you have also been asked to pay $378.47 for the intravitreal injection and
ranibizumab injection.
Service Allowed Amount Coinsurance Member Liability
Intravitreal Injection $311.88 10% $31.19
Ranibizumab Injection $1,736.38 20% $347.28
TOTAL: $378.47
The ranibizumab injection falls within the "Medicare Part B Prescription Drugs" benefit category. The records
show that an office visit was not billed in conjunction with the intravitreal injection and ranibizumab injection.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the cost share for the intravitreal injection and ranibizumab injection provided
on January 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended electroencephalogram (EEG) monitoring
rendered on August 13, 2019.
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 procedure code 95812 is not supported.
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 95812 is electroencephalogram (EEG) extended
monitoring; 41-60 minutes.
We find that CPT code 95812 is not supported in the medical record. Specifically, there is no documentation
that EEG monitoring for 41-60 minutes was performed. Based on this information, we decided that Medicare
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to
pay for the extended electroencephalogram (EEG) monitoring rendered on August 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional routine transportation trips.
You asked the Plan to pre-approve 16 additional routine transportation trips. You say that the requested
additional transportation is necessary since you broke your arm and are unable to drive to your physical therapy
appointments. The Plan denied your request. The Plan says the requested additional transportation trips exceed
the benefit limit. Therefore, coverage criteria has not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve 16 additional routine transportation trips.