Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready to be transferred to an LTACH care. The Plan denied your request. The Plan says LTACH care is not medically necessary and care can be provided in current setting.
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 evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing care needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation rendered on August 27, 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 diagnosis code is not appropriate.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The submitted diagnosis is not appropriate for the billed services. 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 psychiatric diagnostic evaluation rendered on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lightweight portable power wheelchair.You asked the Plan to pre-approvethe wheelchair. You say thatthis is medically necessary.The Plan denied your request. The Plan says this is being requested for community mobility.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal that your personal mobility deficit impairs participation in MRADLs in the home. Your deficit can be helped by a walker, cane, or manual wheelchair. The documentation does not reveal a detailed home accessibility evaluation. The requested wheelchair would not be useful for in-home use.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 wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea lightweight portable power wheelchair
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on May 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also 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 physical therapy provided on May 1, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ConfirmMDx testing provided on August 13, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that the testing was not medically reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that ConfirmMDx testing is covered for the above indications. 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 ConfirmMDx testing was medically reasonable and necessary. Our physician reviewer found that the enrollee is 69-year-old male with elevated PSA of 11.7 ng/mL that was evaluated with prostate biopsy on August 13, 2020, with 12 cores. All samples were benign. The requested testing was medically reasonable and necessary according to the coverage criteria (#1-7) established in the above LCD above. 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 been met. Therefore, we decided that the Plan has to pay for the ConfirmMDx testing provided on August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary to test for malignant
melanoma. The Plan denied your request. The Plan says there is no documentation that the testing already
approved has been done, or that additional testing is needed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the entire panel cannot be covered, as only the BRAF testing is considered reasonable for melanoma.
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 pre-approve genetic testing for the enrollee.
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-of-network provider on October 29, 2020.
You asked the Plan to pay for the service. 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 medical services provided to the enrollee by an out-of-network provider on October 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the Part B drug infusions and its
administration provided on December 3, 2019, and December 12, 2019.
You asked the Plan to reduce the cost share for the Part B drug infusions and its administration. You say that
you should only be obligated to pay the $50 copayment you were quoted. You say you would have opted for
the less expensive treatment if you had known that the medicine was an additional cost. The Plan denied your
request. The Plan says you have been charged the correct cost sharing 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 in-network chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare
Part B and a $45 copayment for visits to in-network specialists.
You have been asked to pay $154.98 which is 20% coinsurance of the allowed amount for the Part B drug
infusion on each date of service. The allowed amount is $774.90. ($774.90 x 20% = $154.98). You have also
been asked to pay a $45 copayment for the administrations of the infusions on each date of service. The Part B
drug infusions fall within the "Medicare Part B prescription drugs" benefit category. The administration of the
infusions falls within the "Physician/Practitioner services, including doctor's office visits" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to reduce the cost share for the Part B drug infusions and its administration provided on
December 3, 2019, and December 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. 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 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-approvelong term acute care hospital (LTACH) services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided On June 20, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford 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 $222 copayment for ambulance services. You have been asked to pay a $222 copayment 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 copayment for ambulance services provided On June 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on September 17, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that the referring provider is also 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 lab services provided on September 17, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure and dental filling provided on August 27, 2020.
You asked the Plan to pay for the dental services. You say that you live on a very fixed income. The Plan denied your request. The Plan says there are no more benefits available for fillings.
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.
The file shows that an unspecified preventive procedure (D1999) was provided. Although the Plan offers a dental benefit in excess of Medicare coverage, this service is not among those covered under this benefit.
The file shows that fillings for teeth #7-10 were provided. We looked at the file, and Medicare rules. The records show that 2 fillings were provided and paid on June 18, 2020. 2 fillings were also approved and paid for on August 27, 2020. Your plan benefits only cover 4 fillings per calendar year. Based on this information, we decided that the Plan's rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the preventive procedure and dental filling provided on August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrocardiogram (93000) provided on October 6, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foran OON electrocardiogram. You say that this service was medically necessary.The Plan denied your request. The Plan says this service was 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 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 forthe electrocardiogram (93000) provided on October 6, 2020, by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment forthe comprehensive electrophysiological evaluation with catheters provided on September 9, 2020.You asked the Plan to reduce the copayment forthe comprehensive electrophysiological evaluation with catheters. You say that you were told there would be a $300 copayment and the bill you received is much higher. You say you would like the pay an amount closer to the $300 copayment you were quoted. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $280 copayment for each Medicare-covered surgical service at an in-network outpatient hospital. The Plan says you must pay a $4,691.59 coinsurance for the comprehensive electrophysiological evaluation with catheters. Based on the Plan contract, however, you cannot be asked to pay more than a $280 copayment for the comprehensive electrophysiological evaluation with catheters. The record shows that this service is considered a surgical procedure. Therefore, we decided that the Plan has to reduce the copayment forthe comprehensive electrophysiological evaluation with catheters provided on September 9, 2020.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation with a contracted tertiary-level oncologist at a tertiary level provider.You asked the Plan to pre-approvethe services. You say that you need to be seen for a second appointment with this provider.The Plan denied your request. The Plan says the doctor's notes provided do not show that you need tertiary care level. The Plan instead, approved you to have a consultation with an in-network, non-tertiary level oncologist.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this condition can safely be treated by in-network oncologist. There is no need for tertiary 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 the services have not been met.Therefore, we decided that the Plan does not have to pre-approvea consultation with a contracted tertiary-level oncologist at a tertiary level provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on September 1, 2020.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you thought that you would only owe a $100 copayment and would not have had the test done if you had known you would owe so much. 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 $510 copayment for nuclear medicine services provided at an outpatient hospital facility. You have been asked to pay a $510 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on September 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 5, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 47120 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 47120 is hepatectomy, resection of liver; partial lobectomy. We find that CPT code 47120 is not supported in the medical record. Specifically, the operative report does not contain documentation of a partial lobectomy for hepatectomy. 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 December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 3, 2020. You asked the Plan to pay for the ambulance services. You say that the enrollee's facility is in lockdown due to COVID and a staff member called for this service. 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 April 3, 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 April 3, 2020.