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

We decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on October 2, 2020.
You asked the Plan to pay for a shoulder-arm orthosis. You say that the enrollee is using the requested medically necessary item with benefit. The Plan denied your request. The Plan says rules for payment have not been met because the record contains inadequate documentation of a video or telephonic visit by the ordering physician to warrant the code billed.
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 pay for a shoulder-arm orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was chronic pain located in the right shoulder. The documentation in the case file does not support that the requested shoulder-arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder-arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the shoulder. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a shoulder-arm orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a shoulder-arm orthosis (L3960) provided on October 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient care services provided June 8, 2020 to June 10, 2020.

You asked the Plan to waive the copayment for the inpatient services. You say that you had surgery and was supposed to be moved to rehab. Due to not being tested for COVID you were not allowed to go to the rehab. You were kept another day in the hospital and is now being billed an additional $250 copay. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 $250 copayment per day for days 1-7 for Inpatient hospital care.

You have been asked to pay $300 copayment per day for days 1-7 for the inpatient services. The inpatient services fall within the Inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient care services provided June 8, 2020 to June 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxcarbazepine 600 mg tablet.

You asked the Plan to pre-approve Oxcarbazepine. You say that this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for your condition under Medicare Part B

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxcarbazepine 600 mg tablet.

Benefits for Oxcarbazepine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic test and a specialist office visit provided by a participating provider on October 16, 2020.
You asked the Plan to waive the copayment for a diagnostic test and a specialist office visit. You say that you did not see the doctor long enough to warrant this kind of copayment. The Plan denied your request. The Plan says the correct copayments have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for outpatient diagnostic tests/diagnostic procedure and a $40 copayment for physician/practitioner services. You have been asked to pay a $50 copayment for a diagnostic test and a $40 copayment for a specialist office visit. The total amount you are being asked to pay is $90 ($50 + $40 = $90). A diagnostic test falls within the outpatient diagnostic tests/diagnostic procedure benefit category and a specialist office visit falls within the physician/practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic test and a specialist office visit provided by a participating provider on October 16, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from September 2, 2020, to October 28, 2020.

You asked the Plan to pay for the home health services. You say that the claims should be paid. The Plan denied your request. The Plan says these claims were not submitted with an appropriate Type of Bill.

The Plan must follow Medicare rules. Medicare rules say that valid TOBs for home health claims are 0322, 0327, 0328, or 0329, or a TOB from the 034X range for services provided outside of a plan of care.

In this case, these claims were submitted with TOB 0323. This is not one of the valid TOBs for home health claims. Therefore, we decided that the Plan does not have to pay for the home health services provided from September 2, 2020, to October 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of blood clot and portion of chest, neck, or brain artery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the removal of blood clot and portion of chest, neck, or brain artery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to have this surgery provided by an OON 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the removal of blood clot and portion of chest, neck, or brain artery to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on October 31, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you feel that you should not owe a copayment for a pre-operative visit. 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 $10 copayment for standard primary care provider visits. You had an office visit on October 31, 2020. Pre-operative visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit provided on October 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in a skilled nursing facility setting.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitation services and regular physician evaluation. Your care needs can be met at a lower level of care.

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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88184, 88185, 88189) provided December 10, 2020.
You asked the Plan to pay for laboratory services. You say that these codes are supported. The Plan denied your request. The Plan says these additions units are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. While the submitted records support 1 unit of CPT code 88184, 7 units of 88185, and 1 unit of 88189 for this date of service as billed, 1 unit of CPT code 88184, 28 units of 88185, and 1 unit of 88189 were previously paid to the same provider for the same date of service. The records do not support 2 units of CPT code 88184, 35 units of 88185, and 2 units of 88189. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88184, 88185, 88189) provided December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided June 16, 2020. (E0745) provided June 16, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that the claim was denied as evidence of misrepresented services and insurance needs medical records to process the claim. So sending the same. Please take it into consideration and process the claim for further payment. The Plan denied your request. The Plan says the records do not support the service billed.
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 pay for the neuromuscular stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that according to the claims data available at the time of the review, the plan was unable to discover any evidence of an established relationship between the member and the ordering physician. The review has determined that the medical records provided do not meet the requirements for Medicare coverage. 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 neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided June 16, 2020. (E0745) provided June 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 24, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no detailed clinical information provided other than the multiple listed diagnoses on the laboratory requisition. Generally, screening for cardiovascular genetic variants would require specific clear diagnostic indications associated with documented patient pathology and based on specific clinical data and findings, especially in an older patient. As such, based on the very limited data provided, this would not meet medical necessity criteria. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 16, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 physician's services. 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 June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on October 21, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you already paid a $75 copayment and disagree with the additional 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 $75 copayment for MRI's and MRA's. You received an MRI on October 21, 2020. The record shows that you were charged a $75 copayment for an MRA. Therefore, you are also responsible to pay the allowed amount of $71.02, which is less than the $75 copayment, for the MRI. You have been asked to pay $71.02 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on October 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ECG provided by an out-of-network provider on September 3, 2019.
You asked the Plan to pay for the ECG. You say that this is a valid code for billing and the claim should be processed for payment. The Plan denied your request. The Plan says the enrollee's plan does not allow for 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 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 ECG provided by an out-of-network provider on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from January 4, 2021 to January 11, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the OON chiropractic services. You say that you do not understand why this is not covered because your brochure says chiropractic is covered with $15 copayments.The Plan denied your request. The Plan says your coverage does not include chiropractic care from OON providers.

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 chiropractic services provided from January 4, 2021 to January 11, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a
participating provider on July 24, 2020, to July 27, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that this should be covered
fully. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $492
copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay a $492 copayment per day for days 1-3 for an inpatient hospital stay. The total
amount you are being asked to pay is $1,476 ($492 x 3 days = $1,476). The correct copayment has been
applied to the services that were provided. An inpatient hospital stay 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 an inpatient hospital stay
provided by a participating provider on July 24, 2020, to July 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using the requested medically necessary items with benefit. The Plan denied your request. The Plan says rules for DME have not been met.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of DME may not contact an individual by telephone regarding the furnishing of a covered item to the individual except in specific circumstances outlined in the Medicare rules section. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis and a suspension sleeve have not been met. Specifically, the Plan has indicated that this enrollee was contacted via an unsolicited phone call regarding provision of the items at issue. As such, no payment may be made for these items. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1833) and a suspension sleeve (L2397) provided on September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided on December 31, 2020 by an out of network provider.
You asked the Plan to pay for the podiatry services. You say that you would like the Plan to pay this claim. The Plan denied your request. The Plan says the services were non emergent nor approved in advance.
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 podiatry services provided on December 31, 2020 by an out of network provider.