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

We decided that the Plan does not have to waive the co-payment for an MRI provided on December 9, 2020.

You asked the Plan to waive the co-payment for an MRI. You say that you disagree with the surgery 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 co-payment for diagnostic radiology provided by a provider other than your primary care physician.

You have been asked to pay a $295 co-payment for an MRI. An MRI 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-payment for an MRI provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift provided on December 8, 2020.

You asked the Plan to pay for a stair lift. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair lift provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization
device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the
enrollee. The Plan denied your request. The Plan says this service 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 pre-approve this service. Our reviewer says that the
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer
found that the Superion device is experimental. More research is needed to show safety and efficacy of the
device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary

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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage.
You asked the Plan to pre-approve additional mileage. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the transportation benefit only allows 24 one-way trips whereas each one-way trip must not exceed 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year, not to exceed 50 miles per one-way trip.
We looked at the file, the Plan's contract and Medicare rules. You are requesting an additional 35 miles for a total of 85 miles per one-way trip. Your contract with the Plan clearly says that each one-way trip must not exceed 50 miles. Therefore, we decided that the Plan does not have to pre-approve additional mileage.
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 disagree with the denial. The Plan denied your
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you
underwent surgery on May 25, 2021. The physical therapy note dated June 3, 2021, states you need contact
guard assist for sitting up, standing down, and walking 175 feet. The records do not support that you require the
intensity of services in an IRF. Specifically, you are not shown to require 15 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for ambulance services provided on February 3, 2021.

You asked the Plan to waive the co-payment for ambulance services. You say that you were transferred due to COVID-19 and 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co-payment for ambulance services.

You have been asked to pay the allowed amount of $212.25, which is less than the $300 co-payment for ambulance services. Ambulance services fall within the ambulance services 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 ambulance services provided on February 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a cochlear implant provided on December 8, 2020.
You asked the Plan to waive the coinsurance for a cochlear implant. You say that you disagree with the way the device was classified. 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 20% coinsurance for DME and related supplies. You received a cochlear implant on December 8, 2020. The total allowed amount is $8,350 and 20% of that is $1,670. You have been asked to pay the total coinsurance amount of $1,670 for a cochlear implant. A cochlear implant
falls within the DME and related 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 coinsurance for a cochlear implant provided on December 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Tl201 thallium (A9505) and aminophyllin injections (J0280)
provided on October 21, 2020.

You asked the Plan to pay for Tl201 thallium and aminophyllin injections. You say that these codes are
supported in the records. The Plan denied your request. The Plan says these codes are not documented.

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 A9505 is thallium tl-201 thallous chloride, diagnostic,
per The definition of J0280 is injection, aminophyllin, up to 250 mg

We find that CPT codes A9505 and J0280 are not supported in the medical record. Specifically, the records do
not show the drugs represented by these codes were administered on the billed date of service. The records
show that different medications were provided. Based on this information, we decided that Medicare rules for
coverage of Tl201 thallium and Aminophyllin injections have not been met. Therefore, we decided that the
Plan does not have to pay for Tl201 thallium (A9505) and aminophyllin injections (J0280) provided on
October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on October 16, 2020.

You asked the Plan to pay for the hearing aids. You say that did not realize, until the claim was rejected, that there was a provider restriction with the Plan. The Plan denied your request. The Plan says that the member did not contact the Plan prior to having the service performed to verify coverage or to request a coverage determination or prior authorization for an out-of-network coverage exception.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by the Plan's hearing aid provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided from the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on October 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and emergency
care provided from March 2, 2019, to March 5, 2019.
You asked the Plan to waive the copayments for an inpatient hospital stay and emergency care. You say that
you feel that the inpatient hospital stay was unnecessary and 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 $300
copayment for days 1-6, per admission, for inpatient hospital care. Your contract with the Plan also clearly says
that you must pay a $90 copayment for emergency care.
You had an inpatient hospital stay from March 2, 2019, to March 5, 2019. Therefore, you are responsible to
pay a $300 copayment for days 1-3 (March 2, 2019, to March 4, 2019). The total amount you owe is: $300
(copayment) x 3 (inpatient days) = $900.
You received emergency care on March 2, 2019. Therefore, you are responsible to pay the $90 copayment.
The total amount you owe is: $990.
You have been asked to pay the total copayment amount of $990 for an inpatient hospital stay and emergency
care. An inpatient hospital stay falls within the inpatient hospital care benefit category. Emergency care 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 copayments for an
inpatient hospital stay and emergency care provided from March 2, 2019, to March 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on September 8, 2020.

You asked the Plan to pay for the psychotherapy 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 psychotherapy services provided on September 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmology services provided on February 26, 2021 by an out of network (OON) provider.

You asked the Plan to pay for ophthalmology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that the referring provider is out-of-network.

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 ophthalmology services provided on February 26, 2021 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14301 and 14302 provided on February 24, 2020.
You asked the Plan to pay for the adjacent tissue transfer or rearrangement 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 CPT codes 14301 and 14302 are not supported in the medical record. Specifically, the operative report did not include documentation of an adjacent tissue transfer or rearrangement of any area; defect 30.1sq cm to 60.0sq cm; therefore code 14301 cannot be verified. The operative report did not include documentation of an adjacent tissue transfer or rearrangement of any area for each additional 30.0sq cm, or part thereof(listed
separately in addition to code for primary procedure); therefore, code 14302 cannot be verified. Based on this information, we decided that Medicare rules for coverage of the adjacent tissue transfer or rearrangement services have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement services coded 14301 and 14302 provided on February 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the core build up (D2950) for tooth # 3 provided on February 10, 2021.

You asked the Plan to reimburse you for the dental service. You say that your dentist advised that you cannot receive a crown without the core build up. You say that you paid for this service out of pocket as a result. You say that The Plan denied your request. The Plan says core build up is not listed as a covered service.

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 reimburse you for the core build up (D2950) for tooth # 3 provided on February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided by an out-of-network provider on December 9, 2020.

You asked the Plan to pay for the echocardiography. You say that the patient was seen for medical necessity and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was not requested.

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 echocardiography provided by an out-of-network provider on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 30, 2020.
You asked the Plan to pay for a neuromuscular stimulator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document provided as proof of delivery states that the item at issue was provided by a supplier other than the billing supplier. The record does not contain an explanation of the relationship between the providing and the billing supplier. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 10, 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 the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on November 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, fifteen hours per week of rehabilitative services with regular physician evaluation.
The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.