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

We decided that the Plan does not have to pay for Train of Four testing (95999) provided January 17. 2019 by out of network provider.You asked the Plan to pay forthe train of four testing. You say that the service was medically necessary.The Plan denied your request. The Plan says code 95999 shares a bundled relationship with a service already paid.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 the train of four testing has a bundled relationship with the intraoperative neuromonitoring services already paid. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forTrain of Four testing (95999) provided January 17. 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 5, 2019.
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 regards 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 June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on January 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT code 29881. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. 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 services. Our reviewer says that the requested assistant surgeon services were not medically reasonable and necessary. Our physician reviewer found that the enrollee underwent a left knee arthroscopic medial partial meniscectomy, synovectomy, and chondroplasty of the medial femoral condyle on January 23, 2019. There is no documentation submitted to support the medical necessity of an assistant at surgery for this enrollee. There is no compelling patient-specific rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to Medicare rules. Therefore, the requested assistant surgeon services would not be considered medically reasonable and necessary for the procedure provided on January 23, 2019.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on January 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on September 27, 2019.
You asked the Plan to waive the copayment for these services. You say that you would like to know why you owe so much. 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 $250 copayment per visit for Medicare-covered surgical, IV therapy, and blood transfusion services at an outpatient hospital.
Review of the file shows that you received outpatient surgical services in the form of arthrocentesis on September 27, 2019. You have been asked to pay a $250 copayment for these services. These services fall within the Medicare-covered surgical, IV therapy, and blood transfusion services at an outpatient hospital 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 outpatient surgical services rendered to you on September 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you were unaware that the plan didn't service the county to which you moved.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on August 16, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the esophagogastroduodenoscopy and the colonoscopy with lesion removal provided on October 24, 2019 by the out of network (OON) provider.You asked the Plan to pay for the outpatient surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the services were not urgent or emergent in nature. The Plan also says the services could be provided in 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the esophagogastroduodenoscopy and the colonoscopy with lesion removal provided on October 24, 2019 by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown on tooth #20 for the enrollee.
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not eligible for this service until 5/20/20.
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. The Plan covers crowns once every 60 months. The records show that a crown was provided on 5/20/15. It has not been a full five years since the last crown. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental crown on tooth #20 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe primary care physician services rendered August 12, 2019.You asked the Plan to waive the coinsurance forthese services. You say that the doctor should not have charged so much for the visit.The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% of the cost for each in-network primary care doctor visit for Medicare-covered benefits. Review of the file shows that the enrollee received primary care physician services on August 12, 2019. The enrollee has been asked to pay 20% of the cost for these services, for a total of $21.13. These services fall within the in-network primary care doctor visit for Medicare-covered benefits benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe primary care physician services rendered on August 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says there are no complex needs that require a rehab physician, or an interdisciplinary approach to rehab care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee is ambulating using a rolling walker at contact guard supervision. He is at minimal assist for toilet transfers. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that his medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection, the computerized ophthalmic diagnostic imaging, and the intravenous injection provided on September 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the injection, the computerized ophthalmic diagnostic imaging, and the intravenous injection provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 3, 2019 by an OON provider.

You asked the Plan to pay for the laboratory services. You say that the laboratory relies on the referring physician to obtain prior authorization. You also say that you should not be penalized for this error. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 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 October 3, 2019 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee has experienced a decline in mobility and is a high fall risk. The Plan denied your request. The Plan says the enrollee does not need to take part in 3 hours of therapy a day, or need an intensive team approach for care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the recent records indicate the enrollee is non-toxic, and encephalopathy is slowly improving. She is afebrile. 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. She is at minimal assist for functional transfers and activities of daily living. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 1, 2019.
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 regards 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 August 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered to you on November 4, 2019.
You asked the Plan to waive the copayment for these services. You say that the charges are incorrect. 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 $150 copayment for each Medicare-covered outpatient hospital facility visit.
Review of the file shows that you received a diagnostic laryngoscopy at an outpatient hospital on November 4, 2019. You have been asked to pay a $150 copayment for these services. These services fall within the Medicare-covered outpatient hospital facility visit 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 outpatient hospital services rendered to you on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on August 1, 2019 by an OON provider.
You asked the Plan to pay for the outpatient office visit. You say that you asked for prior authorization but the enrollee was called in for treatment prior to getting the authorization. The Plan denied your request. The Plan says you are an out-of-network provider. The Plan also says that prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided on August 1, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit and elbow x-ray provided on June 24, 2019 by an OON provider.
You asked the Plan to pay for the outpatient office visit and elbow x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says the rendering provider is non-contracted with the enrollee's Plan. The Plan also says that the enrollee was not directed by a contracted provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit and elbow x-ray provided on June 24, 2019 by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on August 27, 2019.
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied for the services that were provided.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an emergency room visit. An emergency room visit falls within the emergency 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 an emergency room visit provided on August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve the Euflexxa. You say that the medical records provided support the need for the requested drug. The Plan denied your request. The Plan says that the information submitted does not meet the medical necessity guidelines for coverage.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Euflexxa. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of unilateral primary osteoarthritis of the right knee. The records do not show that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective or have adverse effects for the enrollee in this case.

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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve