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 enrollee is not able to go home, even with home health care. You say that the requested services are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of IRF care. The Plan says that the enrollee could receive care in another setting.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for percutaneous vertebroplasty provided from August 22, 2019 to August 23, 2019.
You asked the Plan to waive the coinsurance for percutaneous Vertebroplasty. You say that you expect to recover the charge of $1,097.06. 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 outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received percutaneous vertebroplasty, an outpatient surgical procedure, from August 22, 2019 to August 23, 2019. The allowed amount is $5,485.29 and 20% of that is $1,097.06. You have been asked to pay the total coinsurance amount of $1,097.06 for percutaneous vertebroplasty. Percutaneous vertebroplasty falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 percutaneous vertebroplasty provided from August 22, 2019 to August 23, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were available in-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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Molecular Intelligence profile biomarker testing provided
on March 29, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is an investigational
test.
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 testing. Our reviewer says that the
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee is noted to have metastatic prostate cancer. Tests directly related to prostate cancer and
associated with known treatment are considered medically necessary and reasonable. Broad sweeping panel
testing, inclusive of tests unrelated to prostate cancer or which have no associated therapies, is not considered
medically necessary and reasonable. The documentation does not support that the provided, genetic panel test
was medically necessary and reasonable to diagnosis or manage the enrollee's condition.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the Molecular Intelligence profile biomarker testing provided on March 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 9, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of services.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ambien CR 12.5mg tablet for the enrollee.
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ambien CR 12.5mg tablet for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 30,
2019 and December 6, 2019.
You asked the Plan to waive the copayment for the ER visits. You say that you need to know your medical
expenses. 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 $90
copayment per visit.
You have been asked to pay a $90 copayment for each ER visit. The total amount you owe is $180 ($90/visit x
2 visits = $180). The ER visits fall 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 for the ER visit provided on November 30, 2019 and December 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for routine dental services provided on August 8, 2019.
You asked the Plan to pay for the routine dental services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services are not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Additionally, the Plan requires the use of network providers unless that care is urgent/emergent or not available in-network. Therefore, we decided that the Plan does not have to pay for routine dental services provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork provider on January 9, 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on January 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Electrocardiogram (93005) provided August 21, 2018. 
 
You asked the Plan to waive the copayment for the electrocardiogram. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied. 
 
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 Diagnostic Testing.  
 
You have been asked to pay a $80.67 copayment for the electrocardiogram. The Medicare allowed amount is less than the $100 copayment specified in the contract. The electrocardiogram falls within the Diagnostic Testing benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an Electrocardiogram (93005) provided August 21, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 15, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide 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 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 physician services provided on July 15, 2019
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a tendon sheath injection provided on November 12, 2019. 
 
You asked the Plan to waive the copayment for a tendon sheath injection. You say that this was not a surgical procedure and you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You received a tendon sheath injection at an outpatient hospital facility on November 12, 2019. A tendon sheath injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.  
 
You have been asked to pay a $295 copayment for a tendon sheath injection. A tendon sheath injection falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 tendon sheath injection provided on November 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the medical services you received on December
27, 2019.
You asked the Plan to waive the copay for the services provided. You say that the therapist didn't examine you.
The Plan denied your request. The Plan says the copay was applied appropriately based on the services you
received.
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 $20
copay for each Medicare-covered physical therapy visit.
You have been asked to pay a $20 copay for the services provided. The services fall within the outpatient rehab
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 copay for the medical services you
received on December 27, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for anesthesia services billed with CPT code 01610-QK for date of service November 25, 2019.
You asked the Plan to pay for the anesthesia services. You say that the claim was not correctly processed. You say that you are billing anesthesia supplied by the provider. You say that he is an anesthesiologist and that billing with the QK modifier was correctly. The Plan denied your request. The Plan says that the billed service was denied because the provider did not append the modifier QX or QZ to the CPT code. The Plan says that anesthesia services provided by a CRNA are to be billed with the appropriate modifier to designate whether the service was performed with or without medical direction by a physician.
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. Specifically, the Plan has not shown that the claim in dispute was for services supplied by a CRNA. The records provided show that the claim in dispute was for services supplied by the anesthesiologist. The NPI on the claim is for an MD and the code in dispute was billed as an MD. There is no need for a CRNA modifier because the procedure in dispute is not being billed by a CRNA. The plan has not provided any documentation to support their denial reason. Therefore, we decided that the Plan has to pay for anesthesia services billed with CPT code 01610-QK for date of service November 25, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the first 15 minutes of conscious sedation (D9239)
provided on October 21, 2019.
You asked the Plan to reimburse you for the first 15 minutes of conscious sedation. You say that you
understand that the extractions will not be covered because you already reached your limit earlier in the year.
You say that the alveoloplasty and anesthesia should be covered. You also say that the alveoloplasty was under
2 different codes. The Plan denied your request. The Plan says the annual maximum of $2,000 has been
exceeded.
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 and conscious sedation is a covered
service, the annual maximum of $2,000 has been exceeded. Therefore, we decided that the Plan does not have
to reimburse you for the first 15 minutes of conscious sedation (D9239) provided on October 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for PT provided on November 25, 2019.
You asked the Plan to waive the copayment for PT. You say that you should not owe a copayment for PT. 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 $40 copayment for outpatient rehabilitation services. You have been asked to pay a $40 copayment for PT. PT falls within the outpatient 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 copayment for PT provided on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Traumeel homepathic solution injections (J9173, 20611).
You asked the Plan to pre-approve Traumeel homepathic solution injections. You say that you need this medication to treat your pain. The Plan denied your request. The Plan says this is experimental.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve Traumeel homepathic solution injections. Our reviewer says that the requested drug is not reasonable and necessary at this time. Our physician reviewer found Traumeel homepathic solution is unproven, experimental treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Traumeel homepathic solution injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Traumeel homepathic solution injections (J9173, 20611).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the BiPAP machine rental provided on August 5, 2018. 
 
You asked the Plan to pay for the BiPAP machine rental. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the claim was untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the BiPAP machine rental was not filed until December 16, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the BiPAP machine rental provided on August 5, 2018
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on March 9, 2019. 
 
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim is a duplicate billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Specifically, the record indicates that this claim is a duplicate of another claim that has been processed and paid by the Plan. Therefore, we decided that the Plan does not have to pay for an emergency department visit (99285) provided on March 9, 2019.