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

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided July 2, 2020.
You asked the Plan to pay for the office visit. You say that you do not understand why this claim did not pay
your complete office visit. You understood you had to pay $45 for a specialist but this states you owe $91.80.
The Plan denied your request. The Plan says this claim was processed correctly and applied towards the
deductible per the plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $198 combined deductible for in network and out of network services.
The item or service you asked the Plan to pay for falls within the benefit category Physician/Practitioner
services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is $198 combined deductible. Until you have paid the combined deductible amount, you
must pay the full cost for covered Part B services from in-network or out-of-network providers. This cost
sharing is a contractual obligation that had not been met at the time the office visit was received on July 2,
2020. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99214) provided
July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Viibryd.
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 self-administered drugs are not covered.
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 Viibryd.
Benefits for these services 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiogram (TTE) with Doppler.You asked the Plan to pre-approvethese 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. Medicarerules 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 he enrollee has a history of mitral regurgitation, coronary artery disease with prior myocardial infarction, congestive heart failure, and defibrillator placement. An echocardiogram was performed on July 7, 2020 and a repeat echocardiogram is requested. The records do not support medical necessity of a repeat echocardiogram in a stable patient less than one year from the prior exam.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-approvea transthoracic echocardiogram (TTE) with Doppler.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient office visit (99214) visual field examination (92083) and scanning computerized ophthalmic diagnostic imaging (92134) provided January 20, 2020.You asked the Plan to waive the copayment forthe vision services. You say that you paid your $35 copay at the time of the visit. You have never paid another $35 for the test in the past. If there was a change, you are not aware of it and neither is the doctor office.The Plan denied your request. The Plan says this claim was processed and the correct copayment applied per the Evidence of Coverage.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 $35 copay for each Medicare covered specialist visit and $35 copay for each covered eye exam to diagnose and treat diseases and conditions of the eye for Physician/Practitioner services, including doctor's office visits and Vision care. You have been asked to pay $70 ($35 + $35 = $70) for the vision services. The vision services fall within the Physician/Practitioner services, including doctor's office visits and Vision care benefit categories. 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 foroutpatient office visit (99214) visual field examination (92083) and scanning computerized ophthalmic diagnostic imaging (92134) provided January 20, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February
21, 2020, to February 27, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says an appropriate G and Q code were missing on the claim for the billed dates of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that the denied codes are not supported in the medical record. Specifically, this was not billed with an
appropriate G and Q code. Based on this information, we decided that Medicare rules for coverage of the
services have not been met. Therefore, we decided that the Plan does not have to pay for home health services
provided to the enrollee from February 21, 2020, to February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

e decided that the Plan does not have to pay forthe consultation and report services coded 88323 provided on April 30, 2020.You asked the Plan to pay forthe consultation and report services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 88323 is 1. This code was billed twice on the same day by the same provider, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the consultation and report services have not been met.Therefore, we decided that the Plan does not have to pay forthe consultation and report services coded 88323 provided on April 30, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example, a skilled nursing
facility or home with home health services.
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 rules to
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 enrollee
has been evaluated in the Emergency Department several time, most recently on 12/21/2020, for weakness,
fatigue and loss of appetite. You were discharged home with oral antibiotic therapy. Medical conditions are
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.
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-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waivethe 50% coinsurance charged for dental services provided out of network on June 25, 2020.You asked the Plan to waivethis coinsurance. You say that you did not know the provider was out of network.The Plan denied your request. The Plan says this cost share was charged based on the Plan contract agreement and the providers status with the Plan.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 50% coinsurance for out of network dental services. 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 waivethe 50% coinsurance charged for dental services provided out of network on June 25, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forprocedure codes G0453, 95861 and 95938 provided on December 11, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid,and the medical records clearly record the time required for each procedure.The Plan denied your request. The Plan says that the records provided 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 codeand provide records to support the services billed. In this case, the records provided clearly document the time spent for each code provided during the procedure. Medicare coverage criteria are met. Therefore, we decided that the Plan has to pay forprocedure codesG0453, 95861 and 95938 for services provided to the enrollee on December 11, 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 toopen the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services provided on September 12, 2020.
You asked the Plan to waive the copayment for lab services. You say that you returned the urine sample the day after receiving labs and feel that you should not owe a separate copayment. 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 $10 copayment for lab services. You have been asked to pay a $10 copayment for lab services. Lab services 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 for lab services provided on September 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physical therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe physical therapy services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network physical therapy providers available to you that can provide the care you are requesting.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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to payadditional reimbursement for physician services provided out of network on April 21, 2020.You asked the Plan to payadditional reimbursement. You say that the Plan should pay additional reimbursement toward this bill.The Plan denied your request. The Plan says you provided proof of payment in the amount of $80 and that amount has already been reimbursed. The Plan states there is no other indication that you have paid additional money toward this service.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Theforms are clear that proof of payment for services to be reimbursed is required. There is no proof of payment for these services other than the amount already reimbursed. Therefore, we decided that the Plan does not have to payadditional reimbursement for physician services provided out of network on April 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard for teeth grinding (D9944).
You asked the Plan to pre-approve the dental item. You say that the crowns are necessary. The Plan denied your request. The Plan says occlusal guard for teeth grinding is not listed as a covered 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 pre-approve an occlusal guard for teeth grinding (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for infusion drugs you received on March 27, 2020.
You asked the Plan to waive the coinsurance for the infusion drugs. You say that you are on disability and you would never have agreed to take this drug if you had known the cost. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. You have been asked to pay 20% coinsurance for the infusion drugs. The infusion drugs fall within the Medicare Part B 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 coinsurance for infusion drugs you received on March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network level.
You asked the Plan to pre-approve the referral. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers 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 pre-approve care from out-of-network providers at the in-network benefit level 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 items/services at issue in this appeal. If you choose to see this out-of-network provider, you will owe at the out-of-network benefit level. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network level.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waivethe cost share applied to the deductible for outpatient mental health care provided on August 27, 2020. You asked the Plan to waivethis cost share. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says you had not yet met your deductible at the time of service.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there was a $1250 for deductiblefor 2020. The Plan has followed Medicare rules by clearly disclosing in the contract that there was a deductible. This cost sharing is a contractual obligation that had not been met at the time of service. Therefore, we decided that the Plan does not have to waivethe cost share applied to the deductible for outpatient mental health care provided on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Vertiflex Superion Interspinous Device.You asked the Plan to pre-approveInsertion of interlaminar/interspinousprocess stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that this treatment is medically necessary and appropriate for the enrollee's medical condition.The Plan denied your request. The Plan says medical studies haven't proven that the device is helpful for treatment of the enrollee's health problem.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 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental more research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Vertiflex Superion Interspinous Device
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. You say that you cannot travel to the in-network providers.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 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-approvephysical therapy services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9500, S9502) provided from April 28, 2020, to May 4, 2020.You asked the Plan to pay forhome infusion therapy. You say that these services do not require authorization.The Plan denied your request. The Plan says these services were not billed with valid codes.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 codes S9500 and S9502 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9500, S9502) provided from April 28, 2020, to May 4, 2020.