Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral health services provided on July 18, 2019.
You asked the Plan to pay for the behavioral health services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for behavioral health services provided on July 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 14, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 27235 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27235 is percutaneous skeletal fixation of femoral fracture, proximal end, neck. We find that CPT code 27235 is not supported in the medical record. Specifically, the documentation does not contain a detailed procedure note for percutaneous skeletal fixation of a femoral fracture. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on June 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800) a provider not contracted with Medicare.
You asked the Plan to pay for the POV. You say that before you bought the scooter the customer service person told you that you can buy the scooter and submit reimbursement. The Plan denied your request. The Plan says this item is not approved for reimbursement.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. The provider is not contracted with Medicare. Therefore, we decided that the Plan does not have to pay for power operated vehicle (POV), group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800) a provider not contracted with Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature for the enrollee's power wheelchair.
You asked the Plan to pre-approve the requested feature. You say that the enrollee does not have legs, and the device will assist with lifting him up. The Plan denied your request. The Plan says the item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is not covered by Medicare or the enrollee's plan. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature for the enrollee's power wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on September 5, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you had the same procedure and was only responsible for a $5 copayment. You say that this doesn't seem like a radiology service. 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 $100 per day for Medicare-covered diagnostic radiology services. Covered diagnostic radiology services include ultrasound, nuclear cardiac imaging, PET, MRI and CT scans. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 ultrasound provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management service before and/or after direct patient care (99538) and Hemodialysis (90937) provided on April 26, 2019 through April 27, 2019.
You asked the Plan to pay for the prolonged evaluation and management service before and/or after direct patient care. You say that the billed services are supported by the medical record. The Plan denied your request. The Plan says the documentation submitted do not indicate that the billed services were provided.
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 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour. The CPT Code Manual definition of 90937 is Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription. We asked our coder 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 prolonged evaluation and management service before and/or after direct patient care. Our reviewer says that no records for 4/26/2019 have been submitted for review. No hemodialysis records from 4/27/2019 have been submitted for review. Our reviewer found there is
no documentation to support that these services were provided. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management service before and/or after direct patient care have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management service before and/or after direct patient care (99538) and Hemodialysis (90937) provided on April 26, 2019 through April 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit provided on October 23, 2019.You asked the Plan to waive the copayment foran ER visit. You say that you disagree with the second ER copayment.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 $100 copayment for emergency care. You had an ER visit on October 23, 2019. This is considered a new ER visit. Therefore, you are responsible to pay the $100 copayment. You have been asked to pay a $100 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 foran ER visit provided on October 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 20, 2019.
You asked the Plan to pay for lab tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for musculoskeletal surgery (20999) provided on April 30, 2019.
You asked the Plan to pay for the musculoskeletal surgery. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is not covered when billed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for musculoskeletal surgery (20999) provided on April 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forroutine exam on September 26, 2019.You asked the Plan to pay forthe routine exam. You say that this was not routine and it was an emergency eye exam.The Plan denied your request. The Plan says you exhausted your benefit.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. You exhausted your benefit because you had a previous eye exam on March 1, 2019. Your EOC clearly states, one (1) supplemental routine eye exam every year (includes $0 glaucoma screening).Therefore, we decided that the Plan does not haveto pay forroutine exam on September 26, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical spine facet joint radiofrequency ablation.
You asked the Plan to pre-approve the cervical spine facet joint radiofrequency ablation. You say that this service is medically necessary in order to treat the member's neck pain. The Plan denied your request. The Plan says the member has not had two MBBs at this requested level.
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 pre-approve the cervical spine facet joint radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has not had two medically necessary MBBs with 80% relief or 50% improvement in ability to perform activities of daily living. 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 cervical spine facet joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical spine facet joint radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 3, 2019 by an out-of-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 January 3, 2019 by an out-of-network provider.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay for the ambulance services and ground mileage provided on August 6, 2019.
You asked the Plan to pay for the ambulance services and ground mileage. You say that the enrollee arrived to the emergency room for a gastrostomy tube (G-Tube) replacement due to a faulty G-Tube. The Plan denied your request. The Plan says that the payment for the ambulance response is the responsibility of Original Medicare.
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 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 enrollee's applicable hospice election information. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Therefore, the plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the ambulance services and ground mileage provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on October 10, 2019 by an in-network provider.
You asked the Plan to waive the copayment for vision care. You say that you should not be liable for the cost share due the cost share being different on June 25, 2019. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). You are responsible for a $35 copay for each specialist visit for Medicare-covered services. If the Medicare-allowed amount is less than your copay you will pay the lesser amount. 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 vision care provided on October 10, 2019 by an in-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Hepatitis A vaccine (90471) provided on September 27, 2019.
You asked the Plan to pay for the Hepatitis A vaccine. You say that you were traveling to Egypt and the vaccines were recommended and should be considered preventive. The Plan denied your request. The Plan says the Hepatitis A vaccine is not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Hepatitis A vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Hepatitis A vaccine. Therefore, we decided that the Plan does not have to pay for the Hepatitis A vaccine (90471) provided on September 27, 2019.
Benefits for the Hepatitis A vaccine 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lesion removal provided on September 10, 2019.
You asked the Plan to waive the copayment for the lesion removal. You say that the provider only trimmed your toenails. You say that you are being charged for a service that was not done. 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 $35 copayment for each Medicare-covered podiatry visit. Covered services include diagnosis and the medical or surgical treatment of injuries and diseases of the feet. You have been asked to pay a $35 copayment for the lesion removal. Lesion removal falls within the "Podiatry services" benefit category. The records show that lesions were removed during the visit. 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 lesion removal provided on September 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory home health services provided to the enrollee on February 18, 2019.
You asked the Plan to pay for the services. You say that the oxygen was ordered upon discharge from the hospital. The Plan denied your request. The Plan says the documentation does not contain a diagnosis of severe lung disease or hypoxia-related symptoms or findings such as pulmonary HTN, recurring congestive heart failure due to cor pulmonale or erythrocytosis.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Our MAXIMUS Doctor reviewer says that the services at issue in this case were not medically reasonable or necessary. Our reviewer found that the documentation does not reveal that skilled nursing or skilled therapy services were required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. The progress note from July 2019 documentation does not reveal a medical need for home oxygen. The services do not meet the definition of home health aide services as per Section 50.2 as the documentation does not reveal that the enrollee is homebound. The requested respiratory home health aide services are not necessary to the treatment of the enrollee's illness by the skilled professional staff. Therefore, we decided that the Plan does not have to pay for respiratory home health services provided to the enrollee on February 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on September 17, 2019.
You asked the Plan to waive the coinsurance for the office visit. You say that the appointment was not necessary. You say that you do not want to pay the copayment. The Plan denied your request. The Plan says the coinsurance 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 15% coinsurance for services obtained from a primary care provider. You have been asked to pay $18.15, which is 15% of the allowed amount for the office visit. The allowed amount is $120.98 (15% x $120.98 = $18.15). The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" 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 office visit provided on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on July 30, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the high 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 $225 copayment for CT scans. You have been asked to pay a $225 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 a CT scan provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral lumbar radiofrequency ablation at levels L5-S1, S1-2 and S2-3.You asked the Plan to pre-approvebilateral lumbar radiofrequency ablation at levels L5-S1, S1-2 and S2-3. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. 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 pre-approve bilateral lumbar radiofrequency ablation at levels L5-S1, S1-2 and S2-3. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation used for sacroiliac (SI) joint pain is considered investigational 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 bilateral lumbar radiofrequency ablation at levels L5-S1, S1-2 and S2-3 have not been met.Therefore, we decided that the Plan does not have to pre-approvebilateral lumbar radiofrequency ablation at levels L5-S1, S1-2 and S2-3