Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral sleep appliance (E0486).
You asked the Plan to pre-approve the oral sleep appliance. You say that you would like reconsideration as this
is a continuity of care issue. The Plan denied your request. The Plan says the AHI was in the normal range at
2.7.
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 oral sleep appliance. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the AHI was noted as 2.7, it falls below the minimum criteria (AHI of 5 along with
other medical indications) for consideration of a sleep apnea appliance.
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 oral sleep appliance have not been met. Therefore, we decided that the Plan
does not have to pre-approve an oral sleep appliance (E0486).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device provided on October 18,
2019.
You asked the Plan to pay for a pneumatic compression device (E0676). You say that the pneumatic
compression device was necessary to prevent deep vein thrombosis after the enrollee's surgery. The Plan
denied your request. The Plan says pneumatic compression devices are not covered by Medicare to prevent
deep vein thrombosis during and/or following surgery, at home, or in any setting.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device provided on October 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel for 22 or more drug classes provided on January 7, 2020.
You asked the Plan to pay for the definitive drug panel. You say that this should be paid as medically necessary. The Plan denied your request. The Plan says the order for this testing was requested but not provided.
The Plan must follow Medicare rules. Medicare rules say that laboratory testing may be covered when it is ordered by a treating provider. In this case, the documentation only includes a form noting the testing to be included in the provider's custom panel. No order for this custom panel to be performed for this enrollee is included to show intent to provide this testing for the date of service. Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel for 22 or more drug classes provided on January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on June 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 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 lab work provided on June 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit you had on February 5, 2020.
You asked the Plan to waive the copayment. You say that you are not paying for this. The Plan denied your request. The Plan says you are responsible for the copayment.
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 $40 copayment for each Medicare-covered visit with a specialist. Review of the file shows that you had a specialist visit on February 5, 2020. You have been asked to pay a $40 copayment for the visit. The visit falls within the physician 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 specialist visit you had on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. 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 the drug testing services provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on July 30, 2019. You asked the Plan to waive the copayment for the office visit. You say that you were instructed to follow up with the doctor. You say that the doctor didn't look at your finger and informed you that you didn't need to be seen. The Plan denied your request. The Plan says the copayment 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 $40 copayment for each Medicare-covered specialist visit. You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on July 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the inpatient hospital stays provided from October 7, 2019 to December 27, 2019. You asked the Plan to waive the copayments for the inpatient hospital stays. You say that this is a financial hardship. 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 $370 copayment per day for days 1-5 and $0 copayment per day for days 6-90 for each benefit period. You have been asked to pay a $1,110 copayment for the inpatient hospital stay from October 7, 2019 to October 10, 2019. ($370 x 3 days = $1,100). You have also been asked to pay a $1,480 copayment for the inpatient hospital stay from December 23, 2019 to December 27, 2019. ($370 x 4 days = $1,480). The inpatient hospital stays fall 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 copayments for the inpatient hospital stays provided from October 7, 2019 to December 27, 2019.
Appeal type: Imaging
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 January 14, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 28, 2020 to February 11, 2020 by an out of network (OON) provider.You asked the Plan to pay for chiropractic services. You say that you paid in full for these services and are requesting reimbursement.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 chiropractic services are not covered when performed out-of-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 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 January 28, 2020 to February 11, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on November 25, 2019.You asked the Plan to waive the copayment for an MRI. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0 copayment for mammography and ultrasounds and a $225 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $225 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on November 25, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from September 13, 2019 to October 16, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says this therapist is not eligible to bill through Medicare.
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to participate in the Medicare program. We looked at the file and Medicare rules. The file shows that the psychotherapy services were provided. A Marriage Family Therapist is not eligible to participate in the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided from September 13, 2019 to October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided by an opt-out provider from April 10, 2019 to September 10, 2019.
You asked the Plan to pay for office services. You say that you are on a fixed income and should not be penalized for the provider's error. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider has opted out from Medicare coverage.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for office services provided by an opt-out provider from April 10, 2019 to September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy and core buildup.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says these services are not covered and have been denied.
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 endodontic therapy and core buildup.
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 provider is short staffed and unable to provide the therapy that the enrollee needs to regain strength. You say that the IRF has appropriate staff and equipment to help the enrollee. The Plan denied your request. The Plan says the documentation does not show that the enrollee meets the criteria for coverage of IRF care. The plan says that the enrollee's medical needs could be provided at a lower level of care.
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 he complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical and occupational therapy, but does not require, nor can tolerate, this on an intensive rehabilitation facility therapy program level 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip
You asked the Plan to waive the copayment for an ambulance trip. You say that you requested to leave by private care. You say that you shouldn't be charged for that. 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 $300 copayment for ambulance services. You have been asked to pay a $300 copayment for an ambulance trip. Since an ambulance trip was provided, the correct copayment has been applied. An ambulance trip falls within the ambulance 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 an ambulance trip on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for ECG services (CPT 93010) provided to the enrollee on January 6, 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 the review is already included in the emergency department evaluation and management payment.
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 93010 is "ECG with at least 12 leads; interpretation and report only." We asked our coding 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 pay for the services. Our reviewer says that the services at issue in this case were coded correctly. Our coding reviewer found the medical records indicate that provider performed an emergency procedure, 31500 - Intubation, endotracheal, emergency procedure as well as performing an EKG 93010. These services were billed to the health plan and CPT 31500 was paid. CPT 93010 was not paid as it is bundled into the payment for CPT 31500. The charges for CPT 93010-59-77 performed does not meet the criteria as the medical records do not support the use of a 59 modifier to receive separate reimbursement consideration. We looked at this coder'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 pay for ECG services (CPT 93010) provided to the enrollee on January 6, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the CPAP provided to the enrollee on September 7, 2019.
You asked the Plan to pay for the CPAP. You say that The Plan denied your request. The Plan says that that this 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. The Plan has denied coverage stating the enrollee does not need a replacement CPAP. However, the Plan has not provided any documentation confirming that this request for a CPAP was a replacement for a CPAP the enrollee already had. Without this documentation we are unable to substantiate the Plan's denial rationale. Therefore, we decided that the Plan has to pay for the CPAP provided to the enrollee on September 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an inpatient rehabilitation facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies; however, her functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. The physical therapy provided on June 18, 2020 indicates the enrollee would benefit from low intensity therapy to maximize function. 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 an acute inpatient rehabilitation facility (IRF) admission and services.