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

We decided that the Plan does not have to pay for the office visit provided on April 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like reconsideration because it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan says no authorization was obtained for the services billed.
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 the office visit provided on April 9, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the arm sling (L3650) provided on May 17, 2021, by an
OON provider.
You asked the Plan to pay for the arm sling. You say that the item should be covered. The Plan denied your
request. The Plan says they did not receive a referral from the enrollee's primary care physician to review and
approve.
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 the arm sling (L3650) provided on May 17, 2021,
by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a targeted genomic sequence analysis (0037U) provided on April 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a laboratory service. You say that the test performed is not available through any other laboratory. You also say that you would like reconsideration for the denied claim. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a targeted genomic sequence analysis (0037U) provided on April 5, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rental of oxygen equipment provided January 7, 2021, to February 7, 2021.
You asked the Plan to waive the coinsurance for the rental of oxygen equipment. You say that this copayment should be waived because you cancelled oxygen services. The Plan denied your request. The Plan says the copayment has processed 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 20% coinsurance for durable medical equipment and related supplies. You have been asked to pay a total cost share of $27.37 for the rental of oxygen equipment ($136.87 Medicare-allowed amount x 20% coinsurance). This service falls within the durable medical equipment and related
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 coinsurance for the rental of oxygen equipment provided January 7, 2021, to February 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate denture - maxillary (D5130), mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided February 22, 2021 by an out-of-network (OON) dentist.
You asked the Plan to pay for the immediate upper denture, lower partial denture and tooth extractions. You say that you researched the cost of services prior to receiving them and do not understand why you are not
being reimbursed a full 50% of the cost. The Plan denied your request. The Plan says 50% of the contracted amount of the services provided OON has been covered according to your dental 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. The Plan covers the immediate upper denture, lower partial denture and tooth extractions with 50% coinsurance. If you choose to see an OON dentist, you might be billed for charges above the amount the Plan pays. We looked at the file, and Medicare rules. The Plan provided documentation that 50% of the contracted amount was covered for each service at issue. Based on this information, we decided that the Plan's rules for coverage of the immediate upper denture, lower partial denture and tooth extractions have not been met. Therefore, we decided that the Plan does not have to pay for the immediate denture - maxillary (D5130), mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided February 22, 2021 by an out-of-network (OON) dentist.
Your complaint about being responsible for more than 50% of the cost of the services provided OON is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns provided on February 23, 2021.
You asked the Plan to pay for the crowns. You say that you believed this was covered because it was a
restorative procedure. The Plan denied your request. The Plan says that this is not covered by the Plan.
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 for the
crowns provided on February 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography provided on May 18, 2021 by an out-of-network provider.

You asked the Plan to pay for the echocardiography. You say that you were not told the test would not be covered, you are disabled, and you cannot work in order to be responsible for the bill. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network service.

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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the echocardiography provided on May 18, 2021 by an out-of-network provider.
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 due to a posterior cervical laminectomy you now have C5 palsy and you cannot raise your right arm up and has trouble walking. 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for cervical spine surgery, with resultant C5 palsy, and was discharged home on September 5, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
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 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 weakness, atrial fibrillation with rapid ventricular response and anemia and was discharged home on August 20, 2021. The patient has ongoing weakness. Medical problems are stable. 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 pay for computed tomography (CT) head or brain (70450) provided
May 17, 2021.
You asked the Plan to pay for the CT scan. You say that claim denied as duplicate in error. Please review and
reprocess the claim for reimbursement according to contract. The Plan denied your request. The Plan says this
service is bundled to another service billed on the same day by the same physician, or a physician of the same
specialty in the same billing group, which is considered the same provider.
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, we have confirmed that code the CT
scan has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a
separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) provided May
17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from June 2, 2021, to June 23, 2021 by an out-of-network provider.
You asked the Plan to pay for application of a modality (97014), therapeutic procedure (97110) and physical therapy evaluation (97161). You say that these are post-operative physical therapy services to rehab the knee and break up the scar tissue. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network 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 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 physical therapy provided from June 2, 2021, to June 23, 2021 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission provided February 9, 2021 to March 26, 2021.
You asked the Plan to waive the copayment for the inpatient admission. You say that you were in the hospital due to COVID and was told that you would not have a copay. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Plan benefits.
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 $225 copay per day for days 1-7 for Inpatient hospital care. You have been asked to pay $1575.00 ($225 x 7 days) for the inpatient admission. The COVID-19 waiver for inpatient services at in-network hospitals being covered at 100% of the allowed amount for both COVID-19
related and non-COVID19 related visits for members who tested positive for COVID-19 was effective only until June 1, 2020. The inpatient admission 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 admission provided February 9, 2021 to March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical stimulation device (E0766) 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 the records do not show a newly diagnosed form of brain cancer.
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 the diagnosis is recurrent glioblastoma with multiple prior lines of treatment. The criteria has not been met. 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 an electrical stimulation device (E0766) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on October 15, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation does not support the medical necessity of the individual tests performed or how each test would impact the management of the enrollee or that the provider intended to order this testing.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, genetic testing, was performed for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on October 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office outpatient visit provided April 29, 2021.

You asked the Plan to waive the copayment for the office outpatient visit. You say that you would like this claim reprocessed and the copayment waived. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 $50 copayment for physician specialist visits. 

You have been asked to pay a $50 copayment for the office outpatient visit. This service falls within the physician specialist 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 outpatient visit provided April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291, 99292) provided on September 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". The CPT Code Manual definition of code 99292 is "Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)".
We find that CPT codes 99291 and 99292 are not supported in the medical record. Specifically, the records provided do not show the time spent providing critical care services on the date of service in question. Therefore, the billed codes cannot be verified. 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 critical care services (99291, 99292) provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on April 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for anesthesia. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 anesthesia provided on April 22, 2021 by an out-of-network (OON) provider.