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

We decided that the Plan does not have to pay forthe laboratoryservices (G0482, 84315, 82565) provided on May 4, 2020, by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you were not aware prior authorization was required.The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.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 haveto pay forthe laboratory services (G0482, 84315, 82565) provided on May 4, 2020, by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from March 19, 2020, through April 9, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you saved the insurance money by refusing additional visits. You say that your copayment should be eliminated or reduced. The Plan denied your request. The Plan says the copayments 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 $25 copayment for each Medicare-covered outpatient rehabilitation service visit from an in-network provider. You have been asked to pay a $25 copayment for each physical therapy visit. The total amount you owe is $175 ($25/visit x 7 visits = $175). Physical therapy falls within the "Outpatient rehabilitation services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided from March 19, 2020, through April 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe unspecified preventive procedure (D1999) and re-cement or re-bond implant/abutment supported crown (D6092) provided.You asked the Plan to pay fortheunspecified preventive procedure (D1999) and re-cement or re-bond implant/abutment supported crown (D6092). 


You say that the old crown came off while you were eating. You say that you are appealingfor coverage of the recementing.The Plan denied yourrequest. The Plan says the services are not covered benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe unspecified preventive procedure (D1999) and re-cement or re-bond implant/abutment supported crown (D6092) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the deep sedation (D9223) and therapeutic parenteral drugs (D9612).
You asked the Plan to pre-approve the deep sedation (D9223) and therapeutic parenteral drugs (D9612). You say that allowing 15 minutes for sedation is unrealistic and the drugs are requested to reduce pain post operatively. You say that the use of these medications is extremely useful. The Plan denied your request. The Plan says the services are not covered benefits. 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 the deep sedation (D9223) and therapeutic parenteral drugs (D9612).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on
January 5, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this bill
The Plan denied your request. The Plan says you were charged this copayment 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 $350
copayment for ambulance services.
You have been asked to pay a $350 copayment for the ambulance servicesThis 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 ambulance services you received on January 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEpogen 20,000 units/2 mL vial.You asked the Plan to pre-approveEpogen. You say that this drug should be covered.The Plan denied your request. The Plan says this drug has been approved under you Part D plan.ThePlan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage.Therefore, we decided that the Plan does not have to pre-approveEpogen 20,000 units/2 mL vial.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient surgery coded as 14301, 14302, 19357, 15777 provided on August 9, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient surgery. You say that you request reconsideration for the surgical session rendered. Please note that besides authorization, an in-network exception was also requested as the doctor and physician assistant are non-contracted providers.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 forthe outpatient surgery coded as 14301, 14302, 19357, 15777 provided on August 9, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCPT Code 22869 and 22870.

You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plandenied your request. The Plan says the services are not 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is 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 ofthe services have not been met.Therefore, we decided that the Plan does not have to pre-approveCPT Code 22869 and 22870.
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 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for bilateral lower extremity pain, renal failure, hyperkalemia, urinary tract infection with sepsis and atrial fibrillation. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you
had at an outpatient hospital facility on June 12, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you think this should be covered.
The Plan denied your request. The Plan says you were charged this copayment 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 $180
copayment for advanced imaging services.
You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the advanced imaging
services benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography
(CT) scan you had at an outpatient hospital facility on June 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and related services (99213, G8427, G8484) provided on April 30, 2020, by an out of network (OON) provider.
You asked the Plan to pay for the office visit and related services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied.
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 office visit and related services (99213, G8427, G8484) provided on April 30, 2020, by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a hemoglobin A1c level (83036) performed
on July 22, 2020.

You asked the Plan to waive the copayment for a hemoglobin A1c level. You say that this service was for a
physical check-up and there should be no copayments. The Plan denied your request. The Plan says the correct
copayment was 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 Medicare-covered laboratory tests.

You have been asked to pay a $10 copayment for a hemoglobin A1c level. A hemoglobin A1c level, even when
performed in aid of an annual physical, is a distinct service. A hemoglobin A1c level 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 for a hemoglobin A1c level (83036) performed on July 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe podiatry services provided on July 9, 2020 by an out of network provider.You asked the Plan to pay forthe podiatry services. You say that you thought you were in network and request payment be given for services provided in good faith.The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service 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 forthe podiatry services provided on July 9, 2020 by an out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) visit you had on August 24, 2020.You asked the Plan to waive the copayment forthe ER visit. You say that you should not have to pay this copayment because you had to return to the ER.The Plan denied your request. The Plan says you were charged this copayment 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 $75 copayment for emergency room visits. You have been asked to pay a $75 copayment for the ER visit. This copayment applies regardless of the reason for the visit. 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 decidedthat the Plan does not have to waive the copayment forthe emergency room (ER) visit you had on August 24, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe lab services provided on November 7, 2019.You asked the Plan to pay forthe lab services. The Plandenied your request. The Plan says that these services are not covered.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.You were provided the lab services by a contract provider. The file does not show that the Plan provided notice that the lab services would not be covered. Under Medicare rules, this means the lab services is considered approved by the Plan. You had a reasonable expectation that the services you received would be covered.Therefore, we decided that the Plan has to pay forthe lab services provided on November 7, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro myoelectric orthosis for the enrollee. You asked the Plan to pre-approve a MyoPro myoelectric orthosis. You say that this is medically necessary. The Plan denied your request. The Plan says that the peer reviewed medical literature considers the MyoPro myoelectric orthosis experimental and investigational for this enrollee's clinical scenario. 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 MyoPro myoelectric orthosis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Current guidelines and recommendations regarding robotic myoelectric upper limb prostheses classify them to be "of uncertain utility compared with dose-matched conventional upper limb exercise therapies." Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of a MyoPro myoelectric orthosis. 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 MyoPro myoelectric orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro myoelectric orthosis for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 17, 2020.You asked the Plan to pay for the physical therapy services. The Plan denied your request. 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.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 servicesat issue. We found no exception that would require the Plan to pay for services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on June 17, 2020.
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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. 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 was admitted for surgical treatment of a hip
fracture and was treated for hospital acquire pneumonia. Medical problems are stable. There are no identified
problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not
a reasonable expectation that this enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing provided on June 23, 2020.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing provided on June 23, 2020.