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

We decided that the Plan has to pay for the services provided to the enrollee on July 10, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that a decision was not made within the time frame.
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 documentation submitted by the plan does not contain a rationale for the plan's denial. Without a specific denial rationale and supporting documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided to the enrollee on July 10, 2018.
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot be safely be rehabilitated at the skilled nursing level due to her complex medical situation, high risk for infection, and daily need for physician monitoring. The Plan denied your request. The Plan says that the enrollee is medically stable and does not require frequent medical provider evaluation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 suffered a non-traumatic subdural hemorrhage status post left temporal and frontoparietal craniectomy. The enrollee has residual left gaze preference, cognitive deficits, and impulsivity. She self-extubated and is on Keppra for new-onset seizures. The complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Close neurological condition/status monitoring, monitor and manage renal and hemodynamic parameters are needed to ensure ongoing stability. The enrollee is at moderate to maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy cannot provide what an IRF can provide. This level of intensity can be expected to allow for significant gains in a short period of time, and the enrollee is expected to significantly benefit, and participate. The enrollee does require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehab therapy program. 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 been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services provided to the enrollee from October 2, 2019, to October 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not billed with the correct code.
The Plan must follow Medicare rules. Medicare rules say that all hemodialysis claims must indicate the most recent Urea Reduction Ratio (URR) for the dialysis patient. Code all claims using HCPCS code 90999 along with the appropriate G modifier. We looked at the file and Medicare rules. The documentation provided shows that the dialysis services in question were not billed with appropriate code 90999 as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services provided to the enrollee from October 2, 2019, to October 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 28, 2019 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-network 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 laboratory services provided on June 28, 2019 an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head (70544) provided on September 7, 2019.
You asked the Plan to pay for an MRA of the head. You say that the enrollee had multiple exams on this date. The Plan denied your request. The Plan says payment for this service is included in another procedure code previously billed for this date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 has a bundled relationship with code 70551, which was billed and paid on a separate claim for the same group practice. The services represented by code 70544 are included in code 70551. CPT code 70544 was not billed with a modifier to show that it was a distinct service, nor do the records contain sufficient information to show why a second radiologist performed this service separately for the same image. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for magnetic resonance angiography (MRA) of the head (70544) provided on September 7, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation provided from June 11, 2019 through August 22, 2019.
You asked the Plan to waive the copayments for cardiac rehabilitation. You say that you were not informed of a copayment. You say that you cannot afford this bill. The Plan denied your request. The Plan says the copayments 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 $40 copayment per session in all in-network outpatient settings. You have been asked to pay a $40 copayment for each cardiac rehabilitation visit. The total amount you owe is $1,240 ($40/ visit x 31 visits = $1,240). Cardiac rehabilitation falls within the "Cardiac rehabilitation 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 copayments for cardiac rehabilitation provided from June 11, 2019 through August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to you 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 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 test at issue in this appeal was requested solely for screening purposes. The file shows that you do not have a personal history of cancer but a family history of cancer. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to you on June 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 8, 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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that, to be recognized as a waived test, some CLIA waived tests have unique HCPCS procedure codes and some must have a QW modifier included with the HCPCS code. We looked at the file and Medicare rules. Procedure codes 83861 and 83516 were not billed with the required QW modifier to be recognized as a CLIA-waived test. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen concentrator purchased from an out-of-network provider on June 29, 2019.
You asked the Plan to pay for the portable oxygen concentrator. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 portable oxygen concentrator have not been met. The rules say that only rented OXYGEN equipment is eligible for coverage. Purchased OXYGEN equipment is statutorily non-covered. Therefore, we decided that the Plan does not have to pay for portable oxygen concentrator purchased from an out-of-network provider on June 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 20, 2019 and billed under code G0482.
You asked the Plan to pay for codes G0842 and 80307. You say that this claim should be paid. The Plan denied your request. The Plan says while code 80307 was paid, the documentation submitted did not include a valid physician order or lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed and how the results of this testing will be used.
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 20, 2019 and billed under code G0482.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on September
9, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 to the enrollee on
September 9, 2019.
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 the clinical documentation does not indicate that the enrollee is able to tolerate a minimum of three hours of skilled therapy daily.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee's current tolerance level of PT and OT does not appear to be at the level or intensity needed to fully participate in an intensive rehabilitation facility therapy program such 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services (86235, 85025) provided on April 13, 2018.
You asked the Plan to waive the copayment for lab services. You say that you were prescribed a drug called Cinzia and you explained to the provider that you did not want to incur any additional costs due to being uncertain of the results. The Plan denied your request. The Plan says outpatient diagnostic tests have a $10 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 $10 copayment for outpatient diagnostic tests. You have been asked to pay a $10 copayment for lab services. This services falls within the outpatient diagnostic tests benefit category. The record shows that your cost share of $10.00 was divided and applied to the two CPT codes 85025 and 86235. CPT code 85025 had an allowed amount of $5.18. The allowed amount was less than the cost share. The remaining $4.82 was applied to CPT code 86235 to complete your cost share responsibility of $10.00 ($5.18 + $4.82 = $10.00). 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 laboratory services (86235, 85025) provided on April 13, 2018.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for needle electromyography (95870) and neuromuscular junction testing (95937) provided on June 19, 2019.
You asked the Plan to pay for the needle electromyography and junction testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not support these services.
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 forward sufficient information to substantiate the denial of these services. Therefore, we decided that the Plan has to pay for needle electromyography (95870) and neuromuscular junction testing (95937) provided on June 19, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that because of the enrollee's medical condition a power seat elevation feature is medically necessary. The Plan denied your request. The Plan says power seat elevation features are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Medicare rules say options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair power seat elevation feature.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Magnetic Resonance Angiography (MRA) of the head (70544) provided on April 26, 2019.
You asked the Plan to pay for the MRA of the head. You say that the MRA was medically necessary. The Plan denied your request. The Plan says coverage criteria was not met.
The Plan must follow Medicare rules. Medicare rules say that MRAs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the MRA of the head. Our reviewer says that the records do not support that the MRA was medically necessary. Our physician reviewer found the reviewed documentation does not include a progress note, differential diagnosis, or discussion of requested test. Without the support of the documentation, it is unclear why the study was ordered. 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 MRA of the head have not been met. Therefore, we decided that the Plan does not have to pay for Magnetic Resonance Angiography (MRA) of the head (70544) provided on April 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 11, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must generally receive care from an in-network provider.
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 physician's services provided on June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the panoramic x-ray. We decided that the Plan does not have to
pre-approve the core buildup and crown.
You asked the Plan to pre-approve the core buildup, including any pins when required, porcelain or ceramic
crown, and panoramic x-ray. You say that you do not know what services are covered under your insurance.
You also say that you cannot afford to pay cash for these services. The Plan says that core buildup and crown
are not covered under your benefit plan. The Plan also says that panoramic x-rays are allowed one time every
36 months and you have already exhausted this benefit.
We decided that the Plan has to pre-approve the panoramic x-ray.
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. The Plan covers 1 dental x-ray every year. Medicare rules say that the Plan must provide a clear and accurate description of supplemental benefits, including applicable limitations. The contract does not specify the type of dental x-rays that are covered and does not provide language that clearly limits this benefit to certain types of x-rays. The records to not show that you have already received coverage for a dental x-ray within the same calendar year. The Plan also has not shown that they notified you of the limitations or that the plan directed you to any other document for coverage rules and limitations. Therefore, we decided that the Plan has to pre-approve the panoramic x-ray.
We also decided that the Plan does not have to pre-approve the core buildup and crown.
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, core buildup, including any pins when required, and porcelain or ceramic crown are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the core buildup and crown.
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.