Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on December 13, 2019.
You asked the Plan to reduce the copayment for the office visit. You say that you were advised your copayment would be $20. The Plan denied your request. The Plan says that the $40 specialist copayment applied correctly.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. There were no records submitted to support whether the provider is a primary care physician or a specialist. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on December 13, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs HF System.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic kidney disease, atrial fibrillation, amyloidosis, cardiomyopathy, and NYSHA Class III congestive heart failure. The use of the CardioMEMs device is considered experimental/investigational in nature due to concerns over efficacy. The services are therefore not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a CardioMEMs HF System.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the neck and spine.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is medically necessary. The Plan denied your request. The Plan says that the MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that you meet Medicare coverage criteria for the MRI. Our physician reviewer found you have a history of chronic neck pain and is on narcotics for same. MRI is indicated for a patient with persistent localized neck pain and is over 50 years of age. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the neck and spine.
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: Imaging
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 August 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on July 16, 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 95909 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 95909 is nerve conduction studies; 5-6 studies. We find that CPT code 95909 is not supported in the medical record. Specifically, the intraoperative report does not contain documentation of 5-6 nerve conduction studies. 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 testing services rendered on July 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that these tests may not be available from laboratories that the Plan has contractual agreements with. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 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 September 12, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Routine Electroencephalography (EEG) Procedures (95813), Nerve Conduction Tests (95911) nerve conduction study (95886) neuromuscular junction testing (95937) provided September 13, 2018.
You asked the Plan to pay for the inpatient hospital services. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95813 26 59 1 unit 95911 26 1 unit 95886 26 1 unit 95937 26 1 unit is not supported in the medical record. Specifically, for 95813.26.59 while EEG monitoring was performed, it appears that a diagnostic EEG code, rather than an intraoperative monitoring EEG code was used. For 95911.26 there is no evidence that nerve conduction studies were performed. For 95886.26 while free running and triggered EMGs were performed, it appears that a diagnostic EMG code, rather than an intraoperative monitoring EMG code was used. For 95886.26.59 while free running and triggered EMGs were performed, it appears that a diagnostic EMG code, rather than an intraoperative monitoring EMG code was used. For 95937.26.59 there is no evidence that neuromuscular junction testing was performed. Train of four monitoring is not neuromuscular junction testing.
Based on this information, we decided that Medicare rules for coverage of the inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for Routine Electroencephalography (EEG) Procedures (95813), Nerve Conduction Tests (95911) nerve conduction study (95886) neuromuscular junction testing (95937) provided September 13, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary referral to the provider
You asked the Plan to pre-approve the referral. You say that this is medically necessary, as the other provider overlooked many things and wanted to proceed immediately to surgery. The Plan denied your request. The Plan says the services are available within the primary network, and your enrollee's condition is not an emergency.
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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the referral to a tertiary care facility is not necessary because the services are available within the primary network, and your condition is not an emergency. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary referral to the provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay and the observation stay provided from November 8, 2019 to November 14, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay and the observation stay. You say that you should not owe this cost sharing amount because it is the out-of-network cost share. You say you made multiple requests to be moved to an in-network hospital. 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 $100 copayment per day for days 1-4 for in-network inpatient hospital care and a $100 copayment per day for in-network observation services. You have been asked to pay a $100 copayment for each day of your inpatient hospital stay ($100 x 3 days = $300) and a $100 copayment for each day of the observation stay ($100 x 3 days = $300). The inpatient hospital stay falls within the "Inpatient hospital stay" benefit category. The observation stay falls within the "Outpatient hospital services" benefit category. The record shows your hospital stays were authorized to be paid at the in-network benefit.
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 copayment for the inpatient hospital stay and the observation stay provided from November 8, 2019 to November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on April 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on April 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.

You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria.

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 a spinal cord stimulator. Our reviewer says that the enrollee does not meet criteria. Our physician reviewer found the enrollee has chronic back pain with trigger points. She has not had prior back surgery, Post Herpetic Neuralgia, nerve root plexopathy or CRPS. She had a prior epidural steroid injection and physical therapy. She had a psychological evaluation which found her a good candidate for an implant. The request is for Burst DR stimulator. The enrollee does not have an approved indication for a spinal cord stimulator. The request is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the cost for the ancillary services provided on May 7, 2018.
You asked the Plan to waive the cost for the ancillary services. You say that the ancillary services were paid. You say that you shouldn't be responsible. The Plan denied your request. The Plan says that the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that enrollees must pay a $125 copayment for each Medicare-covered ambulatory surgical center service. The Plan says you must pay an additional $57.20 for the ancillary services. Based on the Plan contract, however, you cannot be asked to pay more than $0 for the ancillary services. The ancillary services were provided during the surgery at an ambulatory surgical center. This means that the ancillary services are included in the $125 copayment. Therefore, we decided that the Plan has to waive the additional cost for the ancillary services provided on May 7, 2018.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 16, 2019, and October 22, 2019.
You asked the Plan to pay for the services. You say that the services should be paid. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 16, 2019, and October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparascopic surgical cholecystectomy for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says it is not considered to be the standard of care to perform a cholecystectomy at the time of marsupialization of a liver cyst.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee experienced right upper quadrant pain and was found to have hepatic cysts. There is no evidence that the enrollee has gallstones, cholecystitis or biliary dysfunction. As such, pre-authorization for a cholecystectomy is not medically necessary or reasonable. It is reasonable for the gallbladder and biliary tree to be inspected at the time of the marsupialization, with findings dictating whether removal is indicated at that time. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laparascopic surgical cholecystectomy for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 30, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 laboratory services rendered on September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on December 17, 2019.
You asked the Plan to pay for the services. You say that this has always been paid for. The Plan denied your request. The Plan says the services were provided by a non-participating provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on December 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-rays (D0230), and the 2 surgical extractions (D7210) provided on December 26, 2019 by an out of network provider.
You asked the Plan to pay for the dental services. You say that you were in severe pain. You say that you called many different dentists to see if they would see you late in the day. You say that this provider is the only one that was available. You also say that the dentist extracted 2 teeth and are requesting to cover part of the $800 bill. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says dental services received out of network are not covered.
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, dental services that you receive out of network are not covered. Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220), the additional periapical x-rays (D0230), and the 2 surgical extractions (D7210) provided on December 26, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the right knee (73721).
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the member is in pain and the MRI is medically necessary. The Plan denied your request. The Plan says the record does not show conservative treatment including activity modification for 6 weeks or physical therapy for at least 3 weeks.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the member does not meet Medicare coverage criteria for the MRI. Our physician reviewer found there is no documentation of the PT program such as PT notes, duration, timing of the therapy and whether there has been re-evaluation by the referring clinician after the therapy. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the right knee (73721).