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

We decided that the Plan does not have to pre-approve venography and ultrasound for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no signs and symptoms of May-Thurner syndrome such as whole left leg swelling or blood clots.

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 on physical examination hyperpigmentation is noted at the ankles bilaterally. There is documentation of an ulcer of the left lower extremity. The only edema noted is in the left foot. There is no documentation of edema throughout either the proximal right lower extremity or the left leg above the foot. The provider has requested arterial studies (a reasonable plan in a patient with diabetes with ulceration) however these results have not been incorporated in the assessment requesting venography. Venous duplex was performed demonstrating no evidence of infrainguinal DVT with evidence of reflux in multiple superficial veins. There was no evaluation of the iliac veins at the time of that examination. The health plan suggests other less invasive options that seem reasonable and should be considered. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve venography and ultrasound for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided on December 28, 2020.
You asked the Plan to pay for foot orthotics. You say that your tendons were shredded so you have no good
support, but the doctor says PT and orthotics will help. The Plan denied your request. The Plan says this item is
not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on December
28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay from January 5
through January 9, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you cannot afford this
copayment. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $295
copayment per day for days 1 - 7 for Inpatient Hospital Care.
You have been asked to pay $1,180 in copayments ($295 per day for days 1 - 7) for the inpatient hospital stay.
The inpatient hospital stay falls within the Inpatient Hospital 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 copayment for the inpatient hospital stay from January 5
through January 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on March 4,
2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for services obtained from a specialist, or under certain circumstances, a nurse practitioner or
physician's assistant in a specialist's office.
Review of the file shows that you received specialist services on March 4, 2021. You have been asked to pay a
$45 copayment for these services. These services fall within the services obtained from a specialist, or under
certain circumstances, a nurse practitioner or physician's assistant in a specialist's office 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 the specialist services rendered on March 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee does not meet CMS criteria for coverage for an admission to an IRF due to lack of medical complexity and high functional level. The enrollee is medically stable (see above) with no evidence of need for supervision by Physical Medicine and Rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy (PT) but does not require an intensive therapy program. IRF admission is not medically necessary based on the lack of medical complexity and high functional level.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 27, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 27, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve ambulance transportation.
You asked the Plan to pre-approve ambulance transportation. You say that you are immobile. The Plan denied your request. The Plan says that ambulance transportation to a doctor's office is not covered.
The Plan follows Medicare rules. Medicare rules say that an emergency is defined as when a prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. 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 ambulance transportation. Our physician reviewer found that you require ambulance transport to and from appoints as you have a suprapubic catheter. You are immobile. Your presenting symptoms do meet prudent layperson criteria for emergency care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance transportation have been met. Therefore, we decided that the Plan has to pre-approve ambulance transportation.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the chiropractic manipulative treatments (98940 x 3), the office visit (99202), and the x-ray exam of the cervical spine (72040) rendered by the out of network (OON) provider from March 19, 2021, through March 26, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 issue reimbursement for the chiropractic manipulative treatments (98940 x 3), the office visit (99202), and the x-ray exam of the cervical spine (72040) rendered by the out of network (OON) provider from March 19, 2021, through March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because you have multiple specialists that assist you every day and you require daily physical and occupational therapy. The Plan denied your request. The Plan says your needed care may be safely provided in a different setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (72192) provided on March 30, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column II code and is not payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 72192 is part of an edit pair with procedure code 74170. Procedure code 74170 is a column one code, and procedure code 72192 is a column two code. Procedure code 74170 has been paid for this date of service, which means that procedure code 72192 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (72192) provided on March 30, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve IRF care.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs to walk again after COVID. The Plan denied your request. The Plan says that the stay is not medically necessary.

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. It appears that the plan's contracted delegate was provided the records for this admission and has failed to forward them to support the decision to deny based on no medical necessity. When we contacted the Plan to forward the medical records, they stated there were no medical records available. Therefore, we decided that the Plan has to pre-approve IRF care.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the benefit amount for eyeglasses provided on November 4, 2020.
You asked the Plan to pay more than the benefit amount for the eyeglasses. The Plan denied your request. The Plan says the total eyewear allowable of $250 was paid.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan paid the correct eyewear allowable of $250. Therefore, we decided that the Plan does not have to pay more than the benefit amount for eyeglasses provided on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on January 15, 2021.

You asked the Plan to waive the copayment for an x-ray. You say that the was post-op and you should not have to pay for it. The Plan denied your request. The Plan says the correct copayment has been applied.

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 outpatient diagnostic tests/x-ray. 

You have been asked to pay a $10 copayment for an x-ray. The correct copayment has been applied to the x-ray that was provided. An x-ray falls within the outpatient diagnostic tests/x-ray 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 an x-ray provided by a participating provider on January 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on January 14, 2021.
You asked the Plan to pay for code 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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 code 97110 is not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97110 provided on January 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve physician services. You say that you would like this to be done by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these 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 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-approve physician services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on March 8, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physical therapy services. 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 physical therapy services provided on
March 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for dental surgery provided by a participating
provider on January 28, 2021, to February 15, 2021.
You asked the Plan to waive the copayment for dental surgery. You say that your copayment should only be
$5. The Plan denied your request. The Plan says the correct copayment has been applied.
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 dental services (Medicare-covered).
You have been asked to pay a $10 copayment for each dental surgery. The total amount you are being asked to
pay is $30 ($10 x 3 visits = $30). The correct copayments have been applied to the services that were provided.
Dental surgery falls within the dental services (Medicare-covered) 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 dental surgery provided by a participating provider on January 28, 2021, to
February 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete bilateral noninvasive physiologic studies of upper or lower extremity arteries and echocardiography to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the complete bilateral noninvasive physiologic studies of upper or lower extremity arteries and echocardiography. You say that you feel these services are medically necessary. The Plan denied your request. The Plan says the requested services can be provided by a network 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 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-approve the complete bilateral noninvasive physiologic studies of upper or lower extremity arteries and echocardiography to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on January 20, 2021 by an out of network (OON) provider.