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

We decided that the Plan does not have to pay for the pathology services provided on July 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the services were provided in good faith. The Plan denied your request. The Plan says the services are not payable.
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 Plan has network providers available who can provide the lab 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 pathology services provided on July 9, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your
request. The Plan says this request cannot be approved.
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 imaging. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has mild coronary risk but no chest pain, no ischemic electrocardiographic changes and
other conditions (pulmonary embolism and aortic regurgitation) to possibly explain her exertional dyspnea
symptoms. In this circumstance, the records to not support the medical necessity for nuclear stress testing.
Coverage criteria for nuclear stress testing are not met since there are no documented covered indications for
the procedure.
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 imaging have not been met. Therefore, we decided that the Plan does not
have to pre-approve myocardial perfusion imaging for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean advanced foot and knee feature for a prosthetic leg.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of documentation that you are a K3 ambulator.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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has the required functional level for the requested items. The medical records do not document that you are a K3 ambulator.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean advanced foot and knee feature for a prosthetic leg.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150) provided on September 2, 2020.You asked the Plan to pay forthe comprehensive oral evaluation. You say that you went for a tooth extraction, and were charged for a comprehensive oral exam. You also say that you contacted the Plan who said this was unusual, and you should have been charged for a problem focused limited oral evaluation.The Plan denied your request. The Plan says this service exceeds the maximum allowed per period.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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on August 18, 2020, and your comprehensive oral evaluation (D0150) benefit has been exhausted.Therefore, we decided that thePlan does not have to pay forthe comprehensive oral evaluation (D0150) provided on September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for vision care provided on March 2, 2020.
You asked the Plan to waive the coinsurance for vision care. You say that this was a routine eye exam 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 20%
coinsurance for diagnosis and treatment for diseases and conditions of the eye for vision care.
The medical records show that you received vision care to diagnose and treat a disease or condition of the eye
on March 2, 2020. The allowed amount is $138.81 and 20% of that is $27.76.
You have been asked to pay the total coinsurance amount of $27.76 for vision care. Vision care falls within the
vision 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 coinsurance for vision care provided on
March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit and does not have to waive
the coinsurance for a Medicare Part B drug provided on January 17, 2020, to January 31, 2020.
You asked the Plan to waive the copayment for a specialist visit and to waive the coinsurance for a Medicare
Part B drug. You say that 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 $50
copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20%
coinsurance for Medicare Part B drugs.
You had a specialist visit on January 17, 2020. Therefore, you are responsible to pay the $50 copayment.
You received Medicare Part B drug injections on January 31, 2020. The total allowed amount is $4,539.66 and
20% of that is $907.93.
The total amount you owe is: $957.93.
You have been asked to pay the total amount of $957.93 for a specialist visit and a Medicare Part B drug. A
specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category.
A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 specialist visit and does not have to waive the coinsurance for a
Medicare Part B drug provided on January 17, 2020, to January 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora Magnetic Resonance Imaging (MRI) scan provided on September 1, 2020.You asked the Plan to waive the copayment forMRI. You say that you were supposed to have an MRI before you left the hospital, so should not be responsible for this amount.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 $250 copaymentfor in-network MRI. You have been asked to pay the allowed amount of $248.31, which is less than the $250 copayment for MRI. MRI 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 fora Magnetic Resonance Imaging (MRI) scan provided on September 1, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that this transfer is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is 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 for the enrollee
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 pay for the ambulance services provided on August 18 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. 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 August 18, 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 August 18 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha Sureclick. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Repatha Sureclick.
Benefits for Repatha Sureclick may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided to you on August 3, 2020, and August 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered when provided 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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided to you on August 3, 2020, and August 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services rendered on June 17, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the enrolleewas on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe physician services rendered on June 17, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a RevoFit system for lower extremity prosthetics.
You asked the Plan to pre-approve RevoFit system. You say that this is medically necessary for the enrollee.
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this is
experimental/investigational, and the enrollee was approved for a standard socket.
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 RevoFit system. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this request appears to exceed the enrollee's medical need as the enrollee was approved for a
standard socket. A review of the RevoFit adjustable closure in the literature does not indicate that there is
sufficient long-term evidence of safety and effectiveness for the use of this device, or that this is the standard of
care in prosthetic management fitting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of RevoFit system have not been met. Therefore, we decided that the Plan does not
have to pre-approve a RevoFit system for lower extremity prosthetics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 28, 2020.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 26, 2020 to
September 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 26, 2020
to September 5, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments foran ER visit, an inpatient hospital stay, specialist visits, X-rays, chiropractic services, outpatient surgery services, and a CT scan provided from June 11, 2020, toAugust 12, 2020.You asked the Plan to waive the copayments foran ER visit, an inpatient hospital stay, specialist visits, X-rays, chiropractic services, outpatient surgery services, and a CT scan. You say that you feel that if the enrollee had not been discharged early he would not have acquired all of these costs. You state that you cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay: a $90 copayment for emergency care, a $425 copayment for inpatient hospital care, a $40 copayment for specialist services, a $35 copayment for X-rays, a $275 copayment for CT scans, a $20 copayment for chiropractic services, and a $375 copayment for outpatient surgery services provided at hospital outpatient facilities.The enrollee received an ER visit, an inpatient hospital stay, specialist visits, X-rays, chiropractic services, outpatient surgery services, and a CT scan provided from June 11, 2020, to August 12, 2020. Therefore, they are responsible to pay their share of the costs-sharing charges.The total amount the enrollee owes is: $1,750. The enrollee has been asked to pay the total copayment amount of $1,750 for an ER visit, an inpatient hospital stay, specialist visits, X-rays, chiropractic services, outpatient surgery services, and a CT scan. An ER visit falls within the emergency carebenefit category. An inpatient hospital stay falls within the inpatient hospital care benefit category. Specialist visits fall within the physician/practitioner services, including doctor's office visits benefit category. X-rays and a CT scan fall within the outpatient diagnostic tests and therapeutic services and suppliesbenefit category.Chiropractic services fall within thechiropractic servicesbenefit category. Outpatient surgery servicesfall within the outpatient surgery services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayments foran ER visit, an inpatient hospital stay, specialist visits, X-rays, chiropractic services, outpatient surgery services, and a CT scan provided from June 11, 2020, to August 12, 2020