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

We decided that the Plan does not have to waive the copayment forthe office visit and ultrasound provided on July 23, 2019.You asked the Plan to waive the copayment forthe office visit and ultrasound. You say that you paid the specialist copayment. You say that this is preventive and you should not be charged an additional copayment.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 $45 copayment for each specialist office visit and a $100 copayment for diagnostic radiology.You have been asked to pay a $45 copayment for the office visit and a $100 copayment for the ultrasound. The office visit within the "Physician/Practitioner services, including doctor's office visits" benefit category. The ultrasound falls "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered diagnostic radiology.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 forthe office visit and ultrasound provided on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemandibular partial denture -flexible base (including any clasps, rests and teeth) (CPT Code D5226) and maxillary partial denture -flexible base (including any clasps, rests and teeth) (CPT Code D5225).You asked the Plan to pre-approvethe dental services. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. This service is not listed in your Preventive & Comprehensive Dental Coverage Customer Handbook as a covered benefit; therefore, it is not covered.Therefore, we decided that the Plan does not have to pre-approvemandibular partial denture -flexible base (including any clasps, rests and teeth) (CPT Code D5226) and maxillary partial denture -flexible base (including any clasps,rests and teeth) (CPT Code D5225).
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pre-approvethe EEG monitoring. We decided that the Plan does not have to pre-approvean inpatient admission.You asked the Plan to pre-approvethese services. You say that the services are medically necessary. The Plan says that the services are not medically necessary.We decided that the Planhas to pre-approvethe EEG monitoring.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve these services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in thiscase. Our physician reviewer found the enrollee was hospitalized for an episode of altered mental status which was potentially suggestive of a seizure. She was subsequently seen for a neurology office visit and further evaluation with long term EEG was ordered. It is generally appropriate and otherwise well supported by current literature and practice standards to perform extended EEG monitoring in such a clinical circumstance. The requested EEG monitoring is the standard of care and is reasonable and medically necessary. Therefore, we decided that the Plan has to pre-approvethe EEG monitoring.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe physician services provided from June 27, 2019 to July 25, 2019.You asked the Plan to pay forthe physician services. You say that you would like the plan to reconsider your request.The Plan denied your request. The Plan says that the services are not covered when billed by a chiropractor.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to theIRE 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 is denying payment for non-covered services billed by a chiropractor. The file shows that you received services from June 27, 2019 to July 25, 2019. The clinic specializes in pain management services. The Plan has not provided documentation showingthat the services received were for chiropractic treatment and not pain management treatment. We find that the plan has not substantiated their reasoning for denial as the provider is a pain management specialist.Therefore, we decided that the Plan has to pay forthe physician services provided from June 27, 2019 to July 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that admission to IRF with daily physician oversight is most appropriate for the enrollee's needs.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 rulesto 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF with close physician or nursing supervision. While the enrollee may benefit from and participate in additional therapies of physical therapy or occupational therapy, the documentation does not reveal that the enrollee requires this on an intensive rehabilitation facility therapy program level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance forthe pelvic prolapse surgery provided from June 12, 2019 to June 13, 2019.You asked the Plan to reduce the coinsurance forthe pelvic prolapse surgery. You say that the procedure should be considered inpatient because you were billed for a hospital bed. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.Therules 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 all other in-network outpatient hospital services (including observation). You have been asked to pay $1,448.87 which is 20% of the allowed amount for the pelvic prolapse surgery. The allowed amount is $7,244.33. ($7,244.33 x 20% = $1,448.87). The pelvic prolapse surgery fallswithin the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows your hospital stay was for outpatient surgery. 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 coinsurance forthe pelvic prolapse surgery provided from June 12, 2019 to June 13, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay forthe inpatient evaluation and management (EM) services provided on September 4, 2019.You asked the Planto pay forthe inpatient EM services. You say that these were two distinct services provided by providers of different specialties. These are separately reimbursable in spite of being billed under the same tax ID number.The Plandenied your request. The Plansaysthatpayment was made for the code 90935 which is a minor surgery. The code 99233 is included in the global charge for the minor surgery code and cannot be separately paid.The Plan must follow Medicare rules. Medicare rules say that the global fee for a surgical procedure includes all additional medical or surgical services required of the surgeon during the postoperative period. Services of other physicians are not included in the surgical package. In this case, the surgical procedure coded as 90935 was provided. The EM services were provided. This is not considered part of the global package because there is no evidence that the provider agreed on transfer of the enrollee's postoperative care. The documentation also supports these two physicians were responsible for different aspects of the enrollee's care.Therefore, we decided that the Planhas to pay forthe inpatient evaluation and management (EM) services provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEuflexxa viscosupplementation injections for the knee.You asked the Planto pre-approvethe Euflexxa injections. You say that you believe that this is the most effective treatment and is preferable to the other options.The Plandenied your request. The Plansaysthere is no evidence that the preferred agents would be less effective. Therefore, the request for Euflexxa is correctly denied.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Euflexxa injections. Our reviewer says that the requested use of Euflexxa is not reasonable and necessary based on the step therapy criteria. Our physician reviewer found the enrollee is a male with knee pain caused by osteoarthritis. The plan requires a trial of Monovisc or Orthovisc prior to approval of Euflexxa. Recordsdo not indicate that the patient has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.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 Euflexxa injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEuflexxa viscosupplementation injections for the knee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa (J7323).You asked the Plan to pre-approveEuflexxa. You say that you do not use Monovisc and Orthovisc.The Plan denied your request. The Plan says the enrollee has not had a trial of Monovisc and Orthovisc as required by step therapy rules.Medicare covers Part B medications when they are reasonable andnecessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Euflexxa. Our reviewer says that the enrollee does not meet criteria for Euflexxa. Our physician reviewer found the Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Euflexxa. The provided medical records do not indicate that the patient has tried and failed the required drugs, nor do they indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of EUFLEXXA have not been met.Therefore, we decided that thePlan does not have to pre-approveEuflexxa (J7323).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on July 29, 2019.
You asked the Plan to pay for the laboratory services (G0483). You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0483) provided on July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on October 22, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you do not agree with the cardiologists your doctor is sending you to. You say you should not be responsible for the copayment. 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 a $50 copayment for each out-of-network Medicare-covered specialist office visit. You have been asked to pay a $50 copayment for the specialist office visit. Thespecialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows you were billed for the services you received.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 forthe specialist office visit provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe medical services provided on May 29, 2019 by out of network (OON) provider, "the medical center".You asked the Planto pay forthe OON medical services. You say that this should be paid even in absence of authorization due to medical necessity.The Plandenied your request. The Plansaysthe enrollee presented for non-emergency services with an OON provider without authorizationbeing obtained. This is not covered by the Plan.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/servicesat 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 Plandoes not haveto pay forthe medical services provided on May 29, 2019 by out of network (OON) provider, "the medical center".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal and microscopic examination of growths provided on May 13, 2019 by out of network provider.
You asked the Plan to pay for the surgical services. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were not urgent or emergent.
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 provider in this case is not a network provider with the Plan. The referring physician is not a network provider either. 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 removal and microscopic examination of growths provided on May 13, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora total electric hospital bed and mat provided from July 10, 2019 through August 9, 2019.You asked the Plan to pay forthe durable medical equipment (DME). You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  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. Fully electric hospital beds are not covered according to the aforementioned citations. Per Medicare guidelines, the height adjustment feature of a fully electric hospital bed is a convenience feature.Therefore, we decided that the Plan does not have to pay fora total electric hospital bed and mat provided from July 10, 2019 through August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe medical services provided on May 16, 2019 by out of network (OON) provider, "the medical center" .You asked the Planto pay forthe OON medical services. You say that this should be paid based on medical necessity.The Plandenied your request. The Plansaysthere is no coverage for non-emergency medical services obtained 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/servicesat 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 Plandoes not haveto pay forthe medical services provided on May 16, 2019 by out of network (OON) provider, "the medical center".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon February 28, 2019 and March 15, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 servicesat 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 February 28, 2019 and March 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ambulatory surgical boot provided  on August 9, 2019.You asked the Plan to pay foran ambulatory surgical boot (L3260). You say that you are a DME supplier and are separate from the hospital.The Plan denied your request. The Plan says ambulatory surgical boots are not covered by Medicare or the Plan.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 an ambulatory surgical boot (L3260) have not been met.Therefore, we decided that the Plan does not have to pay foran ambulatory surgical boot provided on August 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from June13, 2019 to June 24, 2019.You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says there is no valid referral for this service.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 servicesat 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 from June 13, 2019 toJune 24, 2019.