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

We decided that the Plan does not have to pre-approve the Ozempic injectable medication (J3490).
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the
enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Ozempic injectable
medication (J3490).
Benefits for this medication 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 the laboratory services are not supported in the medical record. Specifically, these services were part of an expanded pharmacogenomic panel. These services should be billed with code 81479. These services were billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric evaluation (90792) provided on September 24, 2019.
You asked the Plan to pay for the psychiatric evaluation. You say that you would like reconsideration because you did not receive proper notice of the member's benefit determination. The Plan denied your request. The Plan says the claim was received past the allowed 12 month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the psychiatric evaluation was not filed until October 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric evaluation (90792) provided on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider on February 11, 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 had network providers available who could have provided 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 services provided to the enrollee by an out-of-network provider on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided from July 29, 2020, to September 18, 2020.
You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you disagree with the charges. 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 $275 copayment for days 1-6 for inpatient hospital care. You had an inpatient rehabilitation stay provided from July 29, 2020, to September 18, 2020. Therefore, you are responsible to pay $694.98, which is less than the total copayment amount. You have been asked to pay $694.98 for an inpatient rehabilitation stay. An inpatient rehabilitation stay falls within the inpatient hospital 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 inpatient rehabilitation stay provided from July 29, 2020, to September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology provided on November 10, 2020.
You asked the Plan to pay for the diagnostic radiology. The Plan denied your request. The Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the diagnostic radiology. 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 diagnostic radiology provided on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on November 11, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says authorization for out-of-network services 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 had network providers available to 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 injection services provided on November 11, 2020 by an out of network (OON) provider.
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. You say that the enrollee is weak and has trouble swallowing. The
Plan denied your request. The Plan says the enrollee does not require a team-based approach for therapy or
have issues that need to be managed by a physiatrist.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found
that the enrollee is at contact guard assist level for standing up, bed transfers, and walking using a two-wheeled
walker. He is at a minimal assist level for grooming and dressing, contact guard assist for functional transfers,
and maximum assist for toileting. The enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 19, 2020 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this service was rendered by a non-contracted 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 19, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (28011) provided September 25, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
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 28011 is Tenotomy, percutaneous, toe; multiple tendons. We find that CPT code 28011 is not supported in the medical record. Specifically, multiple tenotomies on each toe is not documented in the operative report and cannot be verified as performed. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (28011) provided September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for altered mental status after recent coiling of cerebral aneurysm. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral x-ray imaging, additional images (D0230) and the unspecified preventative procedure (D1999).

You asked the Plan to pay for the dental services. You say that you did not know these services would not be covered and feel that the Plan should pay for them. The Plan denied your request. The Plan says you have already met your benefit limit for the comprehensive oral exam and the intraoral x-ray imaging. A comprehensive oral exam is only covered once every three years. Your last covered exam was provided in January of 2018, which is less than three years before the date of service in question. Additionally, the Plan only covers one intraoral x-ray procedure per calendar year. The Plan has agreed to cover and pay for the initial intraoral x-ray (D0220), but the additional images (D0230) are not covered as they exceed the Plan's maximum of one per year. The unspecified preventative procedure is not a service that is covered by Medicare or by the Plan's supplemental benefit under any circumstances.

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 comprehensive oral evaluation (D0150), intraoral x-ray imaging, additional images (D0230) and the unspecified preventative procedure (D1999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurodiagnostic services provided from September 3, 2020, to September 15, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says it is the provider's responsibility to bill the primary group health plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to bill the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the neurodiagnostic services provided from September 3, 2020, to September 15, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for emergency care services provided from December 8,
2020, to December 9, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you are appealing this denial
because you did not make the decision to be admitted to the hospital. The Plan denied your request. The Plan
says that the copayment amount you are being charged is correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. 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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage (EOC)
for 2020. We requested this document, but it was not provided to us. Without a copy of the applicable EOC we
cannot determine what cost-sharing - if any - applies to emergency care services. Therefore, the Plan has not
shown that its decision to ask you to pay $120 copayment for emergency care is correct or justified according
to the Plan contract. Therefore, we decided that the Plan has to waive the copayment for emergency care
services provided from December 8, 2020, to December 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81120, 81121, 81275, 81201,81210, 81235, 81270, 81293, 81299, 81301, 81308, 81309, 81318, 81321, 81402, 81403, 81404, 81405 and 81406 provided to the enrollee on November 20, 2020, by non-participating provider.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says CPT codes 81120, 81121 and 81275have not met the associated diagnosis code relationship per CMS ID L36256. The Plan states CPT codes 81201,81210, 81235, 81270, 81293, 81299, 81301, 81308, 81309, 81318, 81321, 81402, 81403, 81404, 81405 and 81406 denied correctly for no authorization on file (all genetic testing not related to pregnancy requires an authorization). The Plan states your office has been notified on multiple occasions prior to this date of service that authorization is required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Furthermore, the rules say that screening tests are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81120, 81121, 81275, 81201,81210, 81235, 81270, 81293, 81299, 81301, 81308, 81309, 81318, 81321, 81402, 81403, 81404, 81405 and 81406 provided to the enrollee on November 20, 2020, by non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the expanded pharmacogenomic panel provided on August
26, 2020.
You asked the Plan to pay for the expanded pharmacogenomic panel. You say that you would like
reconsideration because these services are medically necessary. The Plan denied your request. The Plan says if
one laboratory evaluates multiple genes using a next generation sequencing procedure, the laboratory shall
report only one unit of service.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, the expanded pharmacogenomic panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. The documentation does not show
that the requested pharmacogenomic testing was ordered due to any signs/symptoms of a drug reaction.
There is no evidence that the testing was provided for therapeutic decision-making regarding the need for the
use of any specific drug. Therefore, we decided that the Plan does not have to pay for the expanded
pharmacogenomic panel provided on August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 6, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you were told there was no copayment for the pre-operative appointment. The Plan denied your request. The Plan says the copayment 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 $25 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $25 copayment for the office visit. The office visit falls within the "Physician/practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived as a pre-operative service to 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 office visit provided on November 6, 2020.