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

We decided that the Plan has to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine (72148).You asked the Plan to pre-approvean MRI of the lumbar spine. You say that the services are necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI of the lumbar spine. Our reviewer says that the service is medically necessary. Our physician reviewer found you present with severe persistent low back pain which according to the notes has worsened since your last visit. Of concern is the mention of non-quantifiedlower extremity weakness. This may represent a red flag but enough clinical informationis not included. Nonetheless, the contemplated radiofrequency ablation procedure at multiple levels constitutes a planned surgical procedure. As such, the requested MRI which was done January 21, 2020 would have been medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have been met.Therefore, we decided that the Plan has to pre-approvea magnetic resonance imaging (MRI) of the lumbar spine (72148).If the Plan does not agree with our decision,they can ask us to opena 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, wewill send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe podiatry services provided to the enrollee on September 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the medical records justify the reason for the services.The Plandenied your request. The Plan says there is no network deficiency for the services provided.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 servicesat 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 OON services. Therefore, we decided that the Plan does not have to pay forthe podiatry services provided to the enrollee on September 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic supplies and material (99070) provided on August 1, 2019.You asked the Plan to pay forchiropractic supplies and material. You say that this was medically necessary.The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forchiropractic supplies and material (99070) provided on August 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on June 27, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the documentation did not include a valid physician order 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 find that presumptive and definitive drug testing is not supported in the medical record. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or treatment strategy. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on June 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic testing provided on November 18, 2019.You asked the Plan to pay for the diagnostic testing.The Plan denied your request. The Plan says authorization is required.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 wouldrequire the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for diagnostic testing provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay for a clinic visit (T1015) provided on October 30, 2019.You asked the Plan to pay for a clinic visit. You say that the massages you received helped with your tendonitis and sleep apnea.The Plandenied your request. The Plan says you previously reached your maximum of 6 visits for the year.The rules say that acupuncture services are not covered by Medicare and the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 6 visits a year for the benefit program. We looked at the fileandMedicare rules. The record shows that you received 6 clinic visits in 2019 prior to the date of service at issue. This means you have exceeded the benefit limit for this service. Based on this information, we decided that Medicare rules for coverage of a clinic visit have not been met.Therefore, we decided that the Plan does not have to pay for a clinic visit (T1015) provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe office visit providedon November 16, 2018.You asked the Plan to waive the coinsurance forthe office visit. You say that you were told several times you were covered.The Plan denied your request. The Plan says the claim was reprocessed with an updated allowed amount and 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 50% of the Medicare-allowed amount for each out-of-network primary care provider visit for Medicare-covered services. You have been asked to pay $161.80 which is 50% of the allowed amount for the office visit. The allowed amount is $323.60. ($323.60 x 50% = $161.80). The office visit falls within "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. Thiscost 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 forthe office visit provided on November 16, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory testing provided on October 2, 2019.You asked the Plan to pay forlab tests. You say that you have this health plan as your primary insurance and began coverage on October 1, 2019.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this Plan is your secondary payer insurance and cannot process this claim until after the primary insurance carrier does.The Planmust follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has instructed you to submit this claim to your primary insurance carrier. As the secondary insurer, the Plan cannot be held responsible for lab tests until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forlaboratory testing provided by on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora follow-up visit (99214) provided on May 14, 2019.You asked the Plan to pay for the follow-up visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the billed evaluation and management service, 99214, was bundled as part of the global surgical fee because it was reported within 90 days of the major surgical procedure, 33234.The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for these procedures includes payment for postoperative visits.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the follow-up visit have not been met. Specifically, payment for the follow-up visit is bundled as part of the global surgical fee. Therefore, we decided that the Plan does not have to pay for a follow-up visit (99214) provided on May 14, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance oxygen and supplies (A0422) ALS routine disposable supplies (A0398) and ambulance waiting time (A0420) provided October 1, 2019.You asked the Plan to pay forthe ambulance supplies. You say that please reconsider this denial and approve the services and adjust so that you could pay the copay amount instead of the total billed amount of the services.The Plan denied your request. The Plan says payment for these items is included in the transportation fee. Medicare does not allow for separate billing of these services and supplies.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met.Therefore, we decided that the Plan does not have to pay forambulance oxygen and supplies (A0422) ALS routine disposable supplies (A0398) and ambulance waiting time (A0420) provided October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 17, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 for physician's services provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 17, 2019 to June 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forchiropractic services. You say that you did not know that you needed authorization for these services, but they were medically necessary.The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare, the provider is out-of-network with the Plan, and the prior authorization was not obtained.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 medical services provided on June 17, 2019 to June 28, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided September 27, 2019 to September30, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary.The Plan denied your request. The Plan says that the acute inpatient hospital care was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on September 27, 2019 with a cough and increased shortness of breath. She was evaluated and found to have an exacerbation of Chronic obstructive pulmonary disease (COPD). She was treated with supplemental oxygen, nebulizers, oral steroids and oral antibiotics. She was admitted and continued treatment. The enrolleewas maintained on her medications for hypertension, diabetes and hyperlipidemia. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided September 27, 2019 to September 30, 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: Lab
Decision: Favorable

We decided that the Plan has to pay forlaboratory testing provided on June 9, 2019.You asked the Plan to pay forlab tests. You say that you have out-of-network coverage with this Plan, and the provider was participating in the Medicare program on the date of service in question.The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider and the ordering physician were not eligible to participate in Medicare at the time the services were rendered.The Plan must follow Medicare rules. Medicare rules say that physician who have opted-out of Medicare coverage may still order and certify laboratory services that are payable under Medicare Part B. The rules say that no provider shall receive payment for services furnished to a Medicare beneficiary unless the provider is enrolled in the Medicare program. The rules say that a Medicare health plan must make reasonable and diligent efforts to gather and forward to the IRE sufficient information regarding its decision to deny coverage or payment. The Plan contract says that out-of-network laboratorytesting is covered by the Plan,and enrollees pay $0 copayment for out-of-network laboratorytesting.We looked at the file and Medicare rules. Although the ordering physician had opted-out of Medicare coverage for this date of service, this opt-out did not prohibit  from ordering laboratory testing that would otherwise be covered by Medicare. The Plan has not provided any information to support that the rendering laboratory was not eligible for Medicare coverage on this date of service. The Plan has not provided any evidence to support that the Office of the Inspector General (OIG) has issued an exclusion for the ordering physician or the rendering laboratory. You say that this laboratory does participate in Medicare, and the charges for these tests performed by a laboratory eligible for Medicare payment should not be disqualified simply because the ordering physician is not a Medicare participant. Without supporting evidence, the Plan has not shown that its decision to deny payment for these services is correct or justified according to Medicare rules. Furthermore, the Plan covers out-of-network laboratory testing with $0 cost-share. Therefore, we decided that the Plan has to pay forlaboratory testing provided on June 9, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe core buildup, including any pins when required, provided on September 11, 2019.You asked the Plan to pay forthe core buildup. You say that prior to this enrollee's appointment you called the insurance planto verify the enrollee's benefits and were told that they were covered at 100%. You also say that you were never informed that you are an out-of-network provider.The Plan denied your request. The Plan says this service is not a covered benefit.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 core buildup, including any pins when required, provided on September 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean interspinousstabilization device.You asked the Plan to pre-approvethe device. The Plan denied your request. The Plan says this is not medically 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed.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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvean interspinous stabilization device.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.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 found to be medically reasonable and necessary for you. Our physician reviewer found you have therapy and medical needs that meet criteria for acute level rehabilitation. Care at a lower level would not effectively meet your rehabilitation needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof IRF care have been met.Therefore, we decided that the Plan has to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.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 toopen the case again, we will send you a letter.