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

We decided that the Plan does not have to pay for a Tdap immunization provided on December 10, 2019.You asked the Plan to pay for the Tdap immunization. You say that you went to your provider and the vaccination was given as a preventive measure.The Plan denied your request. The Plan says your medical coverage will only cover immunizations that meet Medicare Part B coverage criteria.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Tdap immunization.Therefore, we decided that the Plan does not have to pay fora Tdap immunization provided on December 10,2019.Benefits for the Tdap immunization 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-rays provided on January 2, 2020.
You asked the Plan to pay for the x-rays. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 for the x-rays provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intubation services coded 31500 provided on July 16, 2019.You asked the Plan to pay forthe intubation services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 31500 is intubation, endotracheal, emergency procedure.We find that CPT code 31500 is not supported in the medical record. Specifically, the documentation submitted didnot include documentation of intubation, endotracheal, emergency procedure. Based on this information, we decided that Medicare rules for coverage of theintubation services have not been met.Therefore, we decided that the Plan does not have to pay forthe intubation services coded 31500 provided on July 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services 
You asked the Plan to pay for the ambulance services. You say that you felt better and refused a transport. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 27, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided on September 18, 2018 by an out of network (OON) provider.You asked the Plan to pay forhome health services. You say that these services should be covered.The Plan denied your request. The Plan says these services were not authorized.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 home health services provided on September 18, 2018 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 5, 2019.You asked the Plan to waive the copayment forthe ambulance transport. The Plan denied your request. The Plan says that you pay a $275 copayment for these services.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 $275 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per day 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 forthe ambulance transport provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on December 9, 2019.You asked the Plan to waive the copayment foran office visit. You say that you disagree with the charges because this was your annual wellness 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 $15 copayment for each primarycare provider visit. The medical records show that you received services beyond an annual wellness visit on December 9, 2019. Therefore, you are responsible to pay the $15 copayment. You have been asked to pay a $15 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 foran office visit provided on December 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reimburse the cost-sharing charges for PT provided from July 22,
2019 to September 27, 2019.
You asked the Plan to reimburse the cost-sharing charges for PT. You say that you thought that you would owe
a $50 copayment and be reimbursed $15 per each service. 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 $50
copayment for out-of-network outpatient rehabilitation services.
You received PT from July 22, 2019 to September 27, 2019 for a total of 10 visits. Therefore, you are
responsible to pay the allowed amount of $30.26 per each PT service. The total amount you owe is: $302.60,
which is less than the total copayment amount. Please contact the provider with any questions regarding
overpayments and refunds.
You have been asked to pay the total copayment amount of $302.60 for PT. PT falls within the outpatient
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 reimburse the cost-sharing charges
for PT provided from July 22, 2019 to September 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the 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 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 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 be able to perform fifteen hours per week of rehabilitative services with 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity (73721).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically 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 the MRI. Our reviewer says that the MRI is medically reasonable and necessary. Our physician reviewer found the enrollee is noted to have chronic knee pain and instability, which appears to be worsening. The enrollee reports a feeling of "dislocation" when walking. Physical examination notes mild instability. Plain radiographs show no bony abnormalities. The patient has done home exercise and worn a knee brace without relief. 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 been met. Therefore, we decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity (73721).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided on August 13, 2019.You asked thePlan to pay forthe services. The Plan denied your request. The Plan says this is a bundled service.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 95999 is "  Unlisted neurological or neuromuscular diagnostic procedure".We find that CPT code 95999 is not supported in the medical record. Specifically, train of four testing is not an unlisted procedure. There is a more appropriate CPT code for train of four testing. Additionally, train of four testing is a bundled procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage ofCPT 95999 have not been met.Therefore, we decided that the Plan does not have to pay forthe train of four testing (CPT 95999) provided on August 13, 2019.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the outpatient mental health services rendered to you on September 10, 2019 to October 27, 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 that the provider opted out of Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the provider has opted out of Medicare; however, a review of the Medicare opt-out provider list does not show that the physician has opted out of Medicare. The Plan has not provided any documentation to support that the services are not payable by Medicare. Therefore, we decided that the Plan has to pay for the outpatient mental health services rendered to you on September 10, 2019 to October 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from August 7, 2019 through August 13, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the enrollee was only admitted to the facility because of the treatment the enrollee received from their provider and should not be responsible for the copayment. The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 the enrollee was admitted on August 7, 2019 and discharged on August 13, 2019. The enrollee was asked to pay a $290 copayment per day from August 8, 2019 through August 12, 2019, days 1-6 of their inpatient hospital care. The enrollee was discharged on August 13, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $290 copayment per day required for days 1-7. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from August 7, 2019 through August 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the item is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no evidence that the enrollee requires frequent and/or immediate repositioning while in bed. Therefore, the requested semi-electric bed is not shown to be medically necessary or 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 a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that this is an urgent care visit so prior authorization was not required. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 for the medical services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the immunotherapy injections provided on
December 2, 2019.
You asked the Plan to waive the copayment for the immunotherapy injections. You say that you were informed
you didn't have to pay $50 for the injection. 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 $50 per
visit to a specialist.
You have been asked to pay a $50 copayment for the immunotherapy injections. The immunotherapy injections
fall within the "Doctor Visits" benefit category. The immunotherapy injections are considered a professional
service that were provided by a specialist. 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
immunotherapy injections provided on December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided by an outpatient hospital facility on September 23, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the diagnostic 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 $225 copayment for surgery services provided in an outpatient hospital facility. The medical records show that you received a diagnostic colonoscopy on September 23, 2019 due to rectal bleeding. Therefore, you are responsible to pay the $225 copayment. You have been asked to pay a $225 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery and other medical 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 copayment for a colonoscopy provided by an outpatient hospital facility on September 23, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for SNF services provided on December 10, 2018 through December 31, 2018.
You asked the Plan to pay for the SNF services. You say that authorization for these services is not required. The Plan denied your request. The Plan says that these services were not authorized by the Plan.
The Plan must follow Medicare rules. Medicare rules say that PPO plans must provide reimbursement for all plan-covered medically necessary services received from non-contracted providers without prior authorization requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have been met. Specifically, prior authorization is not required for services rendered by out-of-network providers. Therefore, we decided that the Plan has to pay for SNF services provided on December 10, 2018 through December 31, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have painful bunions on the right and left foot with some painful toe pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Favorable

We decided that the Planhasto pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Planto pre-approveSNF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthatcare can be received at home with home health care, or at a lower level of care within the nursing home.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 the requested admission is medically reasonable and necessary. Our physician reviewer found the enrollee qualifies for coverage. There are documented skilled therapy needs. The enrollee's mobility status appears to have been less than baseline prior to surgery. A period of skilled services appears to be reasonable to establish a maintenance program and/or to prevent deterioration of the enrollee's condition.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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Planhas to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.