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

We decided that the Plan does not have to pay for home health services provided on November 25, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for home health services. You say that these services were medically necessary. The
Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior
authorization was 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 for home health services provided on November 25,
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 deductible for the office visit provided on October 30,
2019.
You asked the Plan to waive the deductible for the office visit. You say that the facility was in-network. You
say that you did not know the provider was out-of-network. The Plan denied your request. The Plan says the
deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that your deductible is $750, which applies to all items and services except those
specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will
pay our share for your covered medical services. Out-of-network services are not excluded from the deductible.
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $750 deductible applies to out-of-network office visits. This cost sharing is
a contractual obligation that had not been met at the time the office visit was received on October 30, 2019.
Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on
October 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on September 20, 2019 to September 21, 2019.
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 procedure code 95816 is not supported.
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 95816 is electroencephalogram (EEG); including recording awake and drowsy. We find that CPT code 95816 is not supported in the medical record. Specifically, there is no documentation that an EEG was performed on the billed dates of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the services rendered to on September 20, 2019 to September 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services including an Observation Visit and Local Anesthesia (D9430, D9215) provided on September 25, 2019.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says dental observation visits are not a covered service and Local Anesthesia is only covered when used for an approved procedure. Periodontal Maintenance is not a covered procedure.
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 dental services including an Observation Visit and Local Anesthesia (D9430, D9215) provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee out of network from September 17, 2019 to October 23, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee out of network from September 17, 2019 to October 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient surgery provided from October 17, 2019 to October 19, 2019.
You asked the Plan to waive the coinsurance for outpatient hospital surgery. You say that you were told that
your out-of-pocket expense for this would be $120. The Plan denied your request. The Plan says the
coinsurance amount you are being charged is correct.
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 in-network outpatient surgery at an outpatient hospital facility. The allowed amount of this
claim is $4,362.30, resulting in a coinsurance obligation of $872.46.
You have been asked to pay 20% coinsurance for in-network outpatient hospital surgery. Outpatient hospital
surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers 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 outpatient
surgery provided from October 17, 2019 to October 19, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea magnetic resonance imaging (MRI) of the pelvis (72197).You asked the Plan to pre-approvean MRI of the pelvis. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, 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 pelvis. Our reviewer says that the service is medically necessary. Our physician reviewer found this is an unusual case as it is almost unheard of for a partial prostatectomy to be performed for prostate cancer. Coupled with the fact the surgery was done out of country makes the anatomy of the residual gland very difficult to evaluate. While transrectal ultrasound is a reasonable test in most cases to estimate prostate volume the anatomy of the remaining gland and size would be difficult to assess using ultrasound. Since the surgeon needs to assess the volume and orientation of the residual gland in order to safely do the penile prosthesis placement MRI would be the procedure of choice and is medically reasonable and 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 pelvis have been met.Therefore, we decided that the Plan has to pre-approvea magnetic resonance imaging (MRI) of the pelvis (72197).If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided from October 8, 2019 to October 31, 2019.
You asked the Plan to waive the copayments for cardiac rehabilitation services. You say that you were told that the services would be covered and 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 $20 copayment for cardiac rehabilitation services. You received cardiac rehabilitation services from October 8, 2019 to October 31, 2019 for a total of 8 visits. Therefore, you are responsible to pay a $20 copayment per each visit. The total amount you owe is: $20 (copayment) x 8 (cardiac rehabilitation services) = $160. You have been asked to pay the total copayment amount of $160 for cardiac rehabilitation services. Cardiac rehabilitation services fall within the cardiac rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for cardiac rehabilitation services provided from October 8, 2019 to October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on October 2, 2019.
You asked the Plan to pay for the assembly and operation of a pump with oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with oxygenator or heat exchanger (99190) provided on October 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI provided on October 22, 2019.You asked the Plan to waive the copayment foran MRI. You say that you have never been charged this much in the past and 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 20% coinsurance for diagnostic radiology.You received an MRI on October 22, 2019. The allowed amount is $3,082.93 and 20% of that is $616.59.  You have been asked to pay the total coinsurance amount of $616.59 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 foran MRI provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 15, 2019 through September 27, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 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 emergency department (ED) and/or observation care) would span two midnights. The hospital services September 15, 2019 through September 27, 2019 were medically necessary and reasonable. 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 for the acute inpatient hospital care provided from September 15, 2019 through September 27, 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 waive the copayment forinpatient hospital care from September 5, 2019 through September 8, 2019 provided by an in-network provider.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received due to inadequacy.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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).Review of the file shows that you were admitted on September 5, 2019 and discharged on September 8 2019. You were asked to pay a $350 copayment per day from September 5, 2019 through September 7, 2019, days 1-3 of your inpatient hospital care. You were discharged on September 8, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $350 copayment per day required for days 1-4 for in-network inpatient hospital care. 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 forinpatient hospital care from September 5, 2019 through September 8, 2019 provided by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the shoulder.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of the onset of the enrollee's right rotator cuff tear.
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 the MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the enrollee presents with a reported diagnosis of traumatic right shoulder rotator cuff tear. Under consideration is a request for right shoulder MRI. There is no discussion of the history of trauma or onset of right shoulder symptoms. There is no documentation of right shoulder subjective complaints. There are no clinical exam findings documented relative to the right shoulder. There is no discussion of x-ray results relative to the right shoulder. There is no evidence of failed conservative treatment. Therefore, this request for MRI of the right shoulder is not medically reasonable and necessary at this time. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the shoulder.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on December 4, 2019.
You asked the Plan to waive the copayment for the eye exam. You say that the office visit was part of the surgery care. You say that it should be covered under the initial cost of the surgery. 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 $15 for each Medicare-covered exam (diagnosis and treatment for diseases and conditions of the eye).
You have been asked to pay a $15 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up to a surgical procedure. 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 eye exam provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on October 17, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were 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 Plandoes not havetopay fordrug testing services provided to the enrollee on October 17, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says in-network providers can provide the same specialized care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on December 3, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services provided on October 15, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that you called the Plan and were told you were in-network.The Plan denied your request. The Plan says your office contacted the Plan on October 14, 2019 to verify benefits and eligibility. The Plan states the recorded call determined that your office indicated you are an in-network provider.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 provider is not in-network and the enrollee's EOC clearly states, enrollees must pay 100% for out-of-network dental services.Therefore, we decided that the Plan does not have to pay forthe dental services provided on October 15, 2019 by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for daily skilled services or a need for inpatient services after March 15, 2020. Care in the nursing facility with custodial care, or in the home or an assisted living facility with home health services appears to be appropriate.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.