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

We decided that the Plan has to pre-approvea Computed Tomography (CT) scan of the pelvis.You asked the Plan to pre-approveCT scan. You say that you are appealing with records.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because an imaging study of the abdomen is more likely to provide the physician with the details they need in order to treat the enrollee.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested CT scan. Our physician reviewer found this CT scan with and without contrast is reasonable and indicated for evaluation of an enhancing complex renal cyst found on Magnetic Resonance Imaging (MRI). The Bosniak classification system is based upon CT findings and, as such, the Bosniak class cannot be determined from MRI findings.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have been met.Therefore, we decided that the Planhas to pre-approvea Computed Tomography (CT) scan of the pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a portable oxygen concentrator. You say that you were never informed that prior authorization was required for this. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 a portable oxygen concentrator provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you began to feel ill and your blood pressure was very low. You say that your spouse called for an ambulance, but by the time they arrived you were feeling better. You stated that the emergency responders evaluated you and advised you that they could take you to the emergency room, however it could be dangerous due to Covid-19. You say that you decided not to go to the emergency room since you were feeling better and you had a dialysis appointment the next morning. You asked the Plan to cover the cost of the services because you decided not to go due to the risk of Covid-19.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 24, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service the enrollee was treated but not transported by the ambulance. You say that the services should be covered regardless of whether the enrollee was transported or not. You asked the Plan to reconsider their denial of the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 27, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora chest x-ray (71045) provided December 4, 2019.You asked the Plan to pay forthe chest x-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says this code cannot be paid because it shares a Column I / Column II relationship with another code already processed.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 71045 has a bundled relationship with code 71046 which was already paid on the same service date, and cannot be paid as billed. 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 fora chest x-ray (71045) provided December 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided on January 21, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the enrollee has been a patient of yours for over 30 years, so it seemed appropriate to follow his eye care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered
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 January 21, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided February 7, 2020.
You asked the Plan to pay for the psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee self-directed to an out-of-network provider. There were network providers available.
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 service 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 psychotherapy services (90832) provided February 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the provided targeted genomic sequence analysis panel testing (81455) provided on November 10, 2019.
You asked the Plan to pay for the provided targeted genomic sequence analysis panel testing (81455). You say that the provided targeted genomic sequence analysis panel testing was medically necessary. The Plan denied your request. The Plan says the provided targeted genomic sequence analysis panel testing was not medically necessary
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the provided targeted genomic sequence analysis panel testing (81455). Our reviewer says that the provided targeted genomic sequence analysis panel testing was not medically necessary Our physician reviewer found the enrollee is with ER metastatic breast cancer. Caris testing for breast cancer includes AR, ER, HER 2 NEU, MMR, PDL1, PR, and PTEN. Based on the documentation provided, these tests were not medically reasonable or necessary 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 provided targeted genomic sequence analysis panel testing (81455) have not been met. Therefore, we decided that the Plan does not have to pay for the provided targeted genomic sequence analysis panel testing (81455) provided on November 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on December 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chronic care management. You say that it is absolutely against our wish to bill the member; a fellow patient of ours just because of a slight misconception regarding the insurance information. It is our understanding that you; as patient's insurance would like to avoid the inconvenience as well. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 chronic care management provided on December 14, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral-periapical first x-rays (D0220) provided March 19, 2020.
You asked the Plan to pay for the dental x-rays. You say that you believe these x-rays are covered under the Basic plan which what you are paying for. If incorrect please tell you what this plan covers to save your dentist office and yourself time and aggravation. The Plan denied your request. The Plan says this service 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. Services not listed under the list of covered dental codes are not covered by the plan. 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 intraoral-periapical first x-rays (D0220) provided March 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulpal debridement (D3221) provided on March 31, 2020.
You asked the Plan to pay for the pulpal debridement. You say that the provider fixed your tooth and 3 days later the tooth broke in half. You also say that now the provider has to wait until this is resolved so he can fix your tooth correctly. The Plan denied your request. The Plan says this service is not covered under the Plan.
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 the pulpal debridement (D3221) provided on March 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ophthalmological medical examination and evaluation (92014) provided December 17, 2019.
You asked the Plan to waive the coinsurance for the vision services. You say that your provider uses an out of network billing agent and you feel that this claim should be reprocessed as in-network since your provider did your annual Medicare eye exam in-network. The Plan denied your request. The Plan says this claim processed with the correct cost-share 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 50% of the total cost for Medicare covered eye exam to diagnose and treat diseases and conditions of the eye when rendered by an out of network provider. You have been asked to pay $67.17 for the vision services. The vision services fall within the Vision 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 coinsurance for the ophthalmological medical examination and evaluation (92014) provided December 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after July 12, 2020.
You asked the Plan to pre-approve continue SNF care. You say that the enrollee is still in need of physical therapy. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after July 12, 2020 is correct.
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 continue SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 continue SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after July 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on December 11, 2019.
You asked the Plan to waive the copayment for the laboratory services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received laboratory services on the date of service at issue in this appeal. The Plan says that you had not reached your maximum out of pocket of $6700 at the time these services took place. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $10 copayment for Outpatient diagnostic tests. We looked at the file and Medicare rules. The file shows that you received in-network laboratory services on December 11, 2019. The file also shows that you had not met your out of pocket maximum for this date of service. You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests 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 laboratory services provided on December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehab facility, skilled nursing facility, nursing facility, outpatient setting, or home care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with ventilator management, weaning, and tracheostomy care, intravenous antibiotics, surveillance laboratory studies, intermittent hemodialysis, tube feedings, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 18, 2020 by an OON provider.You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you always go to the dentist to get a cleaning twice a year.The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that no benefits are available for procedures performed by an OON provider or outside of the providers contracted period.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 covered when they are received OON.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis provided on February 18, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested consultation/second opinion.
You asked the Plan to pre-approve the consultation/second opinion. You say that you have a rare form of cancer and you would like a second opinion from this provider before putting your life in the care of the Plan's providers. The Plan denied your request. The Plan says generally the member must receive care from a network provider. In most cases, care the member receives from an out-of-network provider will not be covered.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested consultation/second opinion.