Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve the requested physical therapy. The Plan denied your request. The Plan says 
there are no complex issues warranting an out-of-network provider. Additionally, ongoing therapy can at this 
time likely be performed via a self-directed home exercise program. 
 
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-approve physical therapy to be provided by the 
requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on March 22, 2021.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you have been getting the injection for two years and never had a copayment or coinsurance. You say that you don't agree with your responsibility for the claim. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs.
You have been asked to pay $185.22, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $926.11 (20% x $926.11 = $185.22). The denosumab injection falls within the "Medicare Part B Prescription 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 the denosumab injection provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had on
March 4, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you were not in the
hospital, only in a doctor's office. The Plan denied your request. The Plan says you were charged this
coinsurance correctly. The Plan says that this service was not performed in an office setting, but rather in a
clinic on the campus of an outpatient hospital facility. The Plan says that because the allowed amount for this
procedure ($250.34) is less than your copayment obligation, you are responsible for the full allowed 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 $395
copayment for surgery or other services provided at an outpatient hospital.
You have been asked to pay a $395 copayment for the arthrocentesis procedure. The arthrocentesis procedure
falls within the surgery or other services provided at an outpatient hospital 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 arthrocentesis procedure you had on March 4, 2021, at an
outpatient hospital facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the standard of lumbar laminectomy. 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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five office visits (99213) to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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. You are 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-approve five office visits (99213) to be rendered by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) shoulder (73221) provided July 30, 2020.

You asked the Plan to pay for the MRI. You say that the enrollee had multiple exams on this date of service. Attached reports to support level of service. Please reconsider for processing. The Plan denied your request. The Plan says this claim has already been processed.

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 73221 is magnetic resonance imaging, any joint of upper extremity. 

We find that CPT code 73221 is not supported in the medical record. Specifically, the documentation supports 1 unit of 73221-26-RT which has already been approved and paid. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) shoulder (73221) provided July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the office visit (CPT code 99214) provided on January 25, 2021, by a non-Medicare provider.
You asked the Plan to reimburse for the office visit. You say that your previous insurance would pay you when you would submit for reimbursement and you are requesting this health plan do the same. The Plan denied your request. The Plan says the health plan and Medicare cannot pay for this service because you got this service from a provider who chose not receive Medicare funds.
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 by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse for the
office visit (CPT code 99214) provided on January 25, 2021, by a non-Medicare provider.
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 service is medically necessary. The Plan denied your request. The Plan says the service 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 your medical problems are stable and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program.

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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission to an IRF is not medically necessary or reasonable. 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 for an x-ray consultation (76140) provided on March 11, 2021.
You asked the Plan to pay for an x-ray consultation. You say that this is a valid code. The Plan denied your request. The Plan says this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 76140 is not supported in the medical record. Specifically, this code has 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 an x-ray consultation have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray consultation (76140) provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92002) provided on March 23, 2021.

You asked the Plan to pay for a medical eye exam. You say that you would like payment for these services. The Plan denied your request. The Plan says services will only be covered when they are received from a provider in the specified vision network.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have one routine eye exam each calendar year and a $200 allowance toward the purchase and fitting of eyeglasses and pair of lenses or contact lenses with a network optical provider. 

We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The Plan covers these services when they are received from a provider who participates in the Plan's specified vision network. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a medical eye exam (92002) provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a fitness club membership purchased on January 19, 2020, and March 15, 2020.
You asked the Plan to reimburse you for a fitness club membership. You say that you do not know why you were not covered or eligible for reimbursement. The Plan denied your request. The Plan says you were not enrolled with your plan on the date of purchase on January 19, 2020. The Plan also says that the fitness membership is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that the Plan reimburses you up to $300 each calendar year towards your cost for membership in a qualified health club or fitness facility. This benefit does not cover membership fees you pay to non-qualified health clubs or fitness
facilities, including but not limited to, martial arts centers; gymnastics facilities; country clubs, sports clubs and social clubs; and for sports activities such as golf and tennis. The Plan's rules for coverage of gym benefits have not been met. The records show that you enrolled into this plan March 1, 2020, which confirms you were not a member and were not eligible for reimbursement on January 19, 2020. The records also show that the membership at this facility is not a covered benefit for the Wellness Allowance benefit. Therefore, we decided that the Plan does not have to reimburse you for a fitness club membership purchased on January 19, 2020, and March 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 65-year-old female who was admitted to the current acute care hospital with acute hypoxic respiratory failure with acute respiratory distress syndrome requiring intubation, complicated by acute kidney injury, pneumonia, sepsis, atrial fibrillation, Supraventricular tachycardia, posterior reversible encephalopathy, anemia, seizure, and hyperglycemia which was treated and monitored. She required trach and PEG. More recent notes show that she was able to tolerate weaning attempts to continuous positive airway pressure therapy. She requires ongoing weaning and physical therapy (PT) and occupational therapy (OT). The enrollee appears to be improving and requires only short-term additional acute care hospital services which can safely be received at the current facility.

The enrollee does not require any services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time as there was no identified advantage. Transfer may be considered when treatment has completed. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testosterone injection provided on March 17, 2021.

You asked the Plan to pay for therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (96372) and unclassified drugs (J3490). You say that the Plan should pay this claim. The Plan denied your request. The Plan says there was no documentation of support for the deficiency of the substance.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We looked at the file and Medicare rules. The medical records do not support medical necessity for the injection. Based on this information, we decided that Medicare rules for coverage of therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (96372) and unclassified drugs (J3490) have not been met. Therefore, we decided that the Plan does not have to pay for the testosterone injection provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that 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 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 April 1, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), high index lenses (V2782), progressive lenses (V2781), ultraviolet lenses (V2755), anti-reflective coating (V2750), lens tint (V2744) and deluxe lenses (V2702) provided on April 5, 2021.
You asked the Plan to pay for eyeglass frames, high index lenses, progressive lenses, ultraviolet lenses, anti-reflective coating, lens tint and deluxe lenses. You say that there is no explanation of why these items were not covered. You also say that the items that were not covered should have been negotiated with the Plan. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you have a $150.00 allowance coverage limit for eyeglasses, frames, lenses, or contacts every year. We looked at the file and the Plan's rules. The services at issue are not covered benefits of Medicare or the Plan. The records show you received a discounted rate for the enhanced services.
The original price for your progressive lenses was $390, at a Plan discounted price of $175.
The original price for your high index lenses was $95, at a Plan discounted price of $76.
The original price for your ultraviolet lenses was $55, at a Plan discounted price of $10.
The original price for your anti-reflective coating was $150, at a Plan discounted price of $85.
The original price for your lens tint was $125, at a Plan discounted price of $75.
The original price for your deluxe lenses was $12.50, at a Plan discounted price of $10.
The original price for your frames was $165. The Plan paid the allowance benefit per year of $150, which left a balance of $15. The Plan then discounted that price to $12.
Your total responsibility for the non-covered items is $443 ($175 + $76 + $10 + $85 + $75 + $10 + 12 = $443).
Based on this information, we decided that the Plan's rules for coverage of high index lenses, progressive lenses, ultraviolet lenses, anti-reflective coating, lens tint and deluxe lenses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), high index lenses (V2782), progressive lenses (V2781), ultraviolet lenses (V2755), anti-reflective coating (V2750), lens tint (V2744) and deluxe lenses (V2702) provided on April 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
April 23, 2021.

You asked the Plan to pay for the oral evaluation. You say that you do not understand why this routine service
is being denied when it is covered by your benefit. The Plan denied your request. The Plan says only one oral
comprehensive exam can be covered every 36 months. You last had a comprehensive evaluation in July of
2020, which was covered by the Plan. Since it has not been 36 months since your last comprehensive
evaluation, this service is 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 comprehensive exam is requested
in a frequency that is not covered under this benefit. Documentation shows that you previously had a
comprehensive exam less than 36 months ago. Therefore, we decided that the Plan does not have to pay for the
comprehensive oral evaluation (D0150) provided on April 23, 2021.