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

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the patient appears to be stable but has a poor prognosis and may need additional
non-complex short-term acute care services which can be safely completed at the current facility. The patient
does not require services at the LTACH that are not already available and covered at the current facility. There
are no services at the LTACH that the patient requires that are not already available and covered at the current
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time.
Transfer to a lower level of care may be considered soon.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air transportation (A0431) provided on December 10, 2018.
You asked the Plan to pay for air ambulance. You say that obtaining insurance information was delayed. The
Plan denied your request. The Plan says Medicare denies a claim if it is not received by the plan within twelve
months or one calendar year from the date when the services were rendered. The claim was received on
September 1, 2020. This is past the allowed twelve month time frame.
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 air ambulance was not filed until September, 1 2020. 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 air transportation (A0431) provided on December 10, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe inpatient hospital stay and the laboratory work provided by from May 5, 2020, to September 4, 2020.You asked the Plan to waive the copayments forthe inpatient hospital stay and the laboratory work. Yousay that you had diagnostic work-up and findings of nephrotic syndrome secondary to Covid-19. You say multiple antigen and antibody tests performed have been negative. 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 $375 copayment for eachday for days 1 to 5 for in-network Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days and a $10 copayment in-network Medicare-covered lab services. You have been asked to pay a total of $1,915 for the inpatient hospital stay and the laboratory work. The inpatient hospital stay falls within the "Inpatient Hospital Care" benefit category. The laboratory work falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows there were no diagnosis codes related to Covid-19. See chart below.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 forthe inpatient hospital stay and the laboratory work provided from May 5, 2020, to September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and the application of fluoride (D1206) provided on September 1, 2020.
You asked the Plan to pay for the fluoride application. You say that you did not know that the dentist was not participating under your plan until the claim denied. The Plan denied your request. The Plan says fluoride is listed as an excluded service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) and the application of fluoride (D1206) provided on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services tobe provided by the out-of-network provider.You asked the Plan to pre-approve the physician's services The Plan denied your request. The Plan saysperyour Plan Evidence of Coverageyou are only entitlement to receive services from out-of-network providers for emergency or out-of-area urgently needed services.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services tobe provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lens upgrades you received on July 30, 2020.You asked the Plan to pay forthe upgrades. The Plan denied your request. The Plan says lens upgrades are not covered.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover lensupgrades.We looked at the file and the Plan's rules. The records show that you were provided lens upgrades on July 30, 2020. The Plan paid for the exam and lenses, with applicable cost sharing. Lens upgrades are explicitly excluded from coverage under your plan. Based on this information, we decided that the Plan's rules for coverage of the upgrades have not been met.Therefore, we decided that the Plan does not have to pay forthe lens upgrades you received on July 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $125 copayment charged for ambulance transport provided on July 23, 2020.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the Plan contract agreement and the service provided.
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 $125 copayment for ambulance transport. 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 $125 copayment charged for ambulance transport provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dialysis treatments provided from April 27,
2020, through June 29, 2020.
You asked the Plan to waive the copayment for the services. You say that you have a $30 copayment for a
specialist and you go to the clinic for just a check-up, but you are being billed $47.48. The Plan denied your
request. The Plan says the claims were processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received dialysis treatments for three dates of service from April 27, 2020,
through June 29, 2020. You have been asked to pay 20% coinsurance of the allowed amount per visit for
outpatient dialysis treatments. The allowed amount is $237.39 per visit. The total you owe per visit is $47.48
($237.39 x 20% = $47.48). Your EOC states that enrollees must pay 20% coinsurance per treatment for
outpatient dialysis treatments. 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 dialysis treatments
provided from April 27, 2020, through June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing (81402, 81219).
You asked the Plan to pre-approve the genetic testing. You say that the tests are medically necessary. The Plan
denied your request. The Plan says the documentation provided does not support the requested services.
The Plan must follow Medicare rules. Medicare rules say that for laboratories performing single gene
technologies, a sequential genetic testing approach is expected.
We looked at the file and Medicare rules. No records were provided to show results of previous genetic testing.
JAK exon 12 testing cannot be approved unless a negative result was found on BCR-ABL and JAK 2 testing.
There are no records to show other tests were performed. Based on this information, we decided that Medicare
rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve genetic testing (81402, 81219).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 28, 2020, by an out-ofnetwork (OON) provider.
You asked the Plan to pay for a drug test. You say that you provide this lab work in good faith with the
ordering physician. The Plan denied your request. The Plan says prior authorization was not obtained.
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. The referring provider is out-of-network. 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 a drug test
provided on September 28, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory testing provided on October 19, 2020.You asked the Plan to waive the copayment forlab tests. You say that this was part of a routine physical and you feel like you should not be responsible for a copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $10 copayment for lab tests. You have been asked to pay $10 copayment for lab tests. Lab tests fall 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 forlaboratory testing provided on October 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the tissue exam (88305). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these services were not urgent, emergent or authorized in advance.

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 the medical services provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for myocardial imaging (78431) provided on August 28, 2020.
You asked the Plan to pay for the myocardial imaging. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says this is a duplicate claim.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We find that CPT code 78431 is not supported in the record. Specifically, the record indicates that CPT code 78431 was previously approved and paid to this provider for the billed date of service. The documentation submitted does not indicate that this service was rendered more than once. Based on this information, we decided that Medicare rules for coverage of the myocardial imaging have not been met. Therefore, we decided that the Plan does not have to pay for myocardial imaging (78431) provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation therapy (97014, G0283) provided June 10, 2020 to August 12, 2020.
You asked the Plan to pay for electrical stimulation therapy. You say that the plan previously paid for these services back in October 2019 and November 2019. You went to the doctor for treatment thinking the electric stimulation was covered. The Plan denied your request. The Plan says this service is not covered when billed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for electrical stimulation therapy (97014, G0283) provided June 10, 2020 to August 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 13, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anesthesia for nerve block injections.
You asked the Plan to pre-approve anesthesia for nerve block and injection (01992). You say that you need the
facet joint injections for pain relief. The Plan denied your request. The Plan says there is no medical reason to
have sedation with the injections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. There is no documentation supporting medical necessity of conscious
sedation. Based on this information, we decided that Medicare rules for coverage of anesthesia for nerve block
and injection (01992) have not been met. Therefore, we decided that the Plan does not have to pre-approve
anesthesia for nerve block injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for hearing aids. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says the denial of payment for these hearing aids is correct, because this provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on August 24, 2020.You asked the Plan to waive the copayment forthe ambulance ride. You say that you were told you had coverage for the ambulance ride. You say it was covered at no cost to you. 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 $220 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $220 copayment for the ambulance ride. The ambulance ride falls 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 forthe ambulance ride provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to apply the eyewear benefit for eyeglasses purchased on September 11, 2020.
You asked the Plan to apply the eyewear benefit for the eyeglasses. You say that your last eye exam and glasses was on May 10, 2018 so your recent exam and glasses purchase exceeds the 2 year restriction. The Plan denied your request. The Plan says you were not eligible for the eyeglasses allowance until December 20, 2020.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan allows $150 allowance towards eyeglasses every 24 months. We looked at the file and the Plan's rules. The record shows you had an eye exam and purchased glasses on December 21, 2018. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to apply the eyewear benefit for eyeglasses purchased on September 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test provided on July 13, 2020.
You asked the Plan to pay for the drug test. You say that you would like reconsideration because this test was ordered by a treating physician who makes the professional determination of diagnosis and medical necessity to successfully treat the member. The Plan denied your request. The Plan says the submitted documentation does not support 22 or more drug classes.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the record. Specifically, the record does not indicate that 22 or more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test provided on July 13, 2020.