Persius/hicric huggingface dataset:
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 the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
February 18, 2021, through February 19, 2021.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. This admission should have been an observation stay. The echo did not demonstrate any major abnormalities and the enrollee completed a stress test and was admitted overnight.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department (ED) on February 18, 2021 with sudden onset chest pain, which resolved spontaneously shortly after arriving to the ED. From the electrocardiogram: no ischemic changes, troponins negative, palpitations and vague chest discomfort. The enrollee's heart rate was 120 when emergency medical service (EMS) came to her aid. The enrollee converted prior to coming to ED. The echo showed preserved left ventricle (LV) function, ejection fraction (EF) 65%, mild to moderate mitral and aortic regurgitation. The enrollee was admitted; troponins were negative and there were no arrhythmias noted. The enrollee was discharged home on February 19, 2021. The review has determined that the medical record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 18, 2021, through February 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluid flow amniotic allograft injection provided on July 15, 2020.

You asked the Plan to pay for the injection. The Plan denied your request. The Plan says this is 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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the clinical value and effectiveness of fluid flow amniotic allograft injections in the setting of osteoarthritis of the knee has not been demonstrated in the literature. There is no specific clinical rationale for the requested injection.

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 injection have not been met. Therefore, we decided that the Plan does not have to pay for the fluid flow amniotic allograft injection provided on July 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 20, 2020.

You asked the Plan to pay for the ambulance services. You say that the enrollee was treated in place by the medics then triaged to BLS for transport. 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 July 20, 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 provided on July 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on December 10, 2020.

You asked the Plan to pay for the laboratory test. You say that you are a specialized laboratory that provides drug monitoring in good faith at the request of the ordering physician and payment should be allowed. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not 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 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 test provided by an out-of-network provider on December 10, 2020.
Appeal type: Lab
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 September 23, 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 September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the x-rays and office visits provided from November 13, 2017, through January 19, 2019.

You asked the Plan to waive the co-payment for the x-rays and office visits. You say that you continued following up at the facility as requested by the orthopedic surgeon that conducted the surgery. You say that x-rays were the only way to determine how your fracture was healing and you don't understand why you keep receiving invoices. The Plan denied your request. The Plan says the co-payments applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your 2017 contract with the Plan clearly says that you must pay a $30 co-payment for basic radiological services at an in-network specialist's office. Your 2018 contract with the Plan clearly says that you must pay a $15 co-payment for basic radiological services and a $15 co-payment for physician and professional services at an in-network specialist's office. Your 2019 contract with the Plan clearly says that you must pay a $10 co-payment for provider and professional services at an in-network specialist's office.

You have been asked to pay a total of $220 for the x-rays and office visits.

The x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The office visits fall 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 co-payment for the x-rays and office visits provided from November 13, 2017, through January 19, 2019.
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 the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 does require physical and occupational therapy but there is no documented need for an intensive inpatient rehabilitation program. Medically necessary services can be provided in a different 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on April 8, 2020.

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 27780 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 27780 is closed treatment of proximal fibula or shaft fracture; without manipulation.We find that CPT code 27780 is not supported in the medical record. 

Specifically, there is no documentation of closed treatment of proximal fibula or shaft 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 April 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 by an out-of-network provider on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the drug testing services you received on January 26, 2021.

You asked the Plan to adjust the copayment. You say that you cannot afford to pay the out-of-network rate.The Plan denied your request. The Plan says you are responsible for the 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 $65 copayment for out-of-network lab services. Review of the file shows that you were provided drug testing services on January 26, 2021. Per your contract with the Plan, there is a $65 copayment for out-of-network lab services. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $62.14. 

Given that the allowed amount was less than the $65 copayment, you have been asked to pay $62.14 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan.Therefore, we decided that the Plan does not have to adjust the copayment for the drug testing services you received on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payments for radiation therapy provided from November 24, 2020, to November 30, 2020.

You asked the Plan to waive the co-payments for radiation therapy. You say that you were not aware that you would owe a $45 co-payment per each visit. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 co-payment.

You received radiation therapy provided from November 24, 2020, to November 30, 2020, for a total of 3 visits. Therefore, you are responsible to pay a $45 co-payment per each visit. The total amount you owe is: $45
(co-payment) x 3 (radiation therapy visits) = $135.

You have been asked to pay the total co-payment amount of $135 for radiation therapy. Radiation therapy 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 co-payments for radiation therapy provided from November 24, 2020, to November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 20, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 by an out-of-network provider on January 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 7, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser treatment provided on December 1, 2020.
You asked the Plan to pay for the services provided. You say that you paid for the service and are requesting reimbursement. The Plan denied your request. The Plan says the service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. There is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the laser treatment provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite -two surfaces, posterior (D2392) received September 3, 2020 from an opt-out provider.

You asked the Plan to pay for the resin-based composite. You say that the Plan should pay for the requested service.The Plan denied your request. 

The Plan says the provider in this case has opted out of Original Medicare.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.This procedure was rendered by a provider who has opted out of Original Medicare. The Plan contract clearly states that services will be covered only when rendered by a provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. 

Therefore, we decided that the Plan does not have to pay for the resin-based composite -two surfaces, posterior (D2392) received September 3, 2020 from an opt-out provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 17, 2020.
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 29827-22-RT 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 29827-22-RT is arthroscopy, shoulder, surgical; with rotator cuff repair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services provided on December 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were rendered due to an emergency case. The Plan denied your request. The Plan says services rendered by non-participating 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 file shows that the enrollee received an epidural steroid injection for cervical radiculopathy. There are insufficient medical records that show the services were urgent or emergent. The 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 injection services provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the apheresis services provided on August 7, 2020.
You asked the Plan to pay for the services provided. You say that the pathology report demonstrates medical necessity. The Plan denied your request. The Plan says the enrollee does not have the listed conditions for coverage.
The Plan must follow Medicare rules. Medicare rules say that apheresis is only covered under certain medical indications. In this case, the CPT Code Manual definition of code 36514 is therapeutic apheresis; for plasma pheresis. We find that CPT code 36514 is not supported in the medical record. Specifically, the records provided do not show that the enrollee has a condition that is listed for coverage of the services provided. 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 apheresis services provided on August 7, 2020.