Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for eye examination. You say that you disagree with this charge. The Plan denied
your request. The Plan says the denial of payment for this service is correct, because this provider is out-ofnetwork
with the Plan and 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 medical services provided on September 4,
2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on February 20, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you weren't aware of the difference between diagnostic and preventive. You say that you could have declined the test if you knew of the expense. The Plan denied your request. The Plan says the claim reprocessed to only apply the $175 copayment.
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 $175 copayment after the deductible is met for each outpatient surgery and/or services at an in-network ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $175 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that polyps were removed, which is considered a surgical procedure.
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 colonoscopy provided on February 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of lumbar spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no failure of a recent six-week trial of provider-directed treatment and clinical re-evaluation after the treatment period.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have back pain and radiculopathy in the setting of prior back surgeries. There is no evidence of new injury. There are no reports of lower extremity weakness or bowel/bladder control issues. The examination noted no significant findings. Basic radiographs have not been submitted for review. There is no documentation of the enrollee's response to standard therapy (OTC meds, Rx meds, RICE, home exercise, PT/OT, wt. loss). As such, the documentation does not support that the requested MRI is currently medically necessary or reasonable. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of lumbar spine for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decipher testing provided to the enrollee on January 14, 2020.You asked the Plan to pay for the testing services. You say that the test is a more accurate predictor of survival outcomes.The Plan denied your request. The Plan says the enrollee is not at high risk for prostate cancer recurrence.The Plan follows Medicare rules. Medicare rules say that Decipher testing is only covered under certain medical indications.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 testing services. Our physician reviewer found that the enrollee had newly diagnosed prostate cancer at the time the test in question was performed. At that time, the enrollee was stage T1c, had not yet undergone initial treatment, and had not yet experienced a recurrence. There is no evidence that secondary surgery was being considered. As such, the documentation does not support that the performed test was medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Decipher testing provided to the enrollee on January 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided on August 7, 2019.You asked the Plan to pay forthe chest x-ray. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim did not include the appropriate primary, first-listed of principal diagnosis.The Plan must follow Medicare rules. Medicare rules say that the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Specifically, a secondary only diagnosis code cannot be used as the primary, first-listed or principal diagnosis for any procedure or service.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71045) provided on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided to the enrollee on October 26, 2019.You asked the Plan to pay for the pathology services. You say that the claim is coded correctly.The Plan denied your request. The Plan says the physician interpretation is paid through the clinical laboratory fee schedule payment.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 85060 is blood smear, peripheral, interpretation by physician with written report. Medicare rules say that services furnished to hospital outpatients are paid under the OPPS to the hospital or facility. This means that the plan pays for all services provided to the enrollee within the facility claim. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided to the enrollee on October 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an out of network ophthalmologist.You asked the Plan to pre-approve the out of network consultation. You say that the enrollee has no confidence in his original surgeon. You say that there are very few board certified oculoplastic surgeons in Alabama.The Plan denied your request. The Plan says the requested provider is non-participating. The Plan says that they have qualified participating providers with expertise in ocuplastics that can provide the requested services.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 out of network consultation. Our reviewer says that out of network care is not medically necessary. Our physician reviewer found the enrollee had ectropion that can be treated surgically by an ophthalmologist within the health plan's network. Although the enrollee and his optometrist prefer he see an ophthalmologist outside of the network and outside of the area, there is no compelling medical or other reason by which the health plan would be obligated to cover this out of network care. The health plan has also provided access to the appropriate services within the network. There is likewise no emergent condition or special services required that would necessitate treatment by the non-network ophthalmologist.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 out of network consultation have not been met.Therefore, we decided that the Plan does not have to pre-approve a consultation with an out of network ophthalmologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for crown for tooth 4 (D2740) and root canal (D3320) provided November 11, 2019 to December 3, 2019.
You asked the Plan to pay for the dental service. You say that you are requesting reimbursement for dental services that you had paid for. The provider was in-network until sometime this past summer. Your previous dental services in May were paid for. The Plan denied your request. The Plan says the request for crowns exceeds the benefit limitation of 1 procedure a year. The root canal is not covered under the plan benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for crown for tooth 4 (D2740) and root canal (D3320) provided November 11, 2019 to December 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says skilled services are no longer needed.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora knee brace (HCPCS L1833 and HCPCS L2397( provided to the enrollee on December 12, 2019.You asked the Planto pay forthe brace. You say that this should be paid for.The Plandenied your request. The Plansaysfor any DMEPOS item to be covered by Medicare, the patient's medical records must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of the items ordered.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPTcode.In this case, the CPT Code Manual definition of the denied codes is:HCPCS L1833:Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelfHCPCS L2397:Addition to lowerextremity orthosis, suspension sleeveWe 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 brace. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the medical record provided does not include sufficient information to meet Medicare's criteria to substantiate/validate the necessity for the type of Durable Medical Equipment provided to the enrollee and billed to his health plan.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 brace have not been met.Therefore, we decided that the Plandoes not haveto pay fora knee brace (HCPCS L1833 and HCPCS L2397( provided to the enrollee on December 12, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided from July 17, 2019 to July 18, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the observation charges because you feel that you received inpatient services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. The medical records show that you received observation services after an ER visit from July 17, 2019 to July 18, 2019. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for an ER visit. An ER 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 ER visit provided from July 17, 2019 to July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the walker and pneumatic walking boot provided on December 10, 2019.
You asked the Plan to pay for the walker and pneumatic walking boot. You say that you did not know prior authorization was required. The Plan denied your request. The Plan says that you did not obtain prior authorization.
The rules state that Preferred Provider Organization (PPO) plans must provide reimbursement for all plan-covered medically necessary services received from non-contracted providers without prior authorization requirements. PPO Plans must provide reimbursement without prior authorization. Under Medicare rules, this means the walker and pneumatic walking boot is considered approved by the plan Therefore, we decided that the Plan has to pay for the walker and pneumatic walking boot provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 12, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveBystolic tab 5mgYou asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested medication is denied as a benefit exclusion.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 Plandoes not haveto pre-approveBystolic tab 5mg
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 24, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on January 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.You asked the Plan to pre-approve continued physical therapy services. You say that you need these services.The Plan denied your request. The Plan says these services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 continued physical therapy services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had extensive prior therapy visits and the documentation notes do not reveal evidence of significant objective functional improvement from this therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide ongoing treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. You should be able to transition to an independent home exercise 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 continued physical therapy services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received at a lower level of 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable, with no evidence of need for supervision by PMR physician. There is no need for acute rehab nursing care. You may benefit PT/ST/OT, but you do not require an intensive therapy program. IRF admission is not medically necessary based on current functional status, dementia, and confusion. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on November 26, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on November 26, 2019.