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

We decided that the Plan does not have to pay fortherapeutic exercises provided by a chiropractor from May 26, 2020, to June 30, 2020.You asked the Plan to pay forthese services. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says any services not related to manual manipulation of the spine are not covered.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 servicesat issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fortherapeutic exercises provided by a chiropractor from May 26, 2020, to June 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical extraction (D7210), the bone replacement graft (D7953), and the limited oral evaluation (D0140) provided on September 17, 2020.You asked the Plan to pay forthe dental services. You say that you have the optional dental coverage that covered extractions and oral surgery. You say that you were not informed that the services would not be covered. You also say that your family dentist referred you to this provider.The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services that you receive from a dental provider who hasopted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program.Therefore, we decided that the Plan does not have to pay forthe surgical extraction (D7210), the bone replacement graft (D7953), and the limited oral evaluation (D0140) provided on September 17, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown (D2740) and core buildup, including any pins when required (D2950) provided on July 23, 2020.You asked the Plan to pay forthe crown and core buildup. You say that these services may have been covered when the provider checked your 2019 benefits. You also say that the procedure was scheduled for 2020, and your benefits had changed.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe crown (D2740) and core buildup, including any pins when required (D2950) provided on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on August 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 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 services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drugs provided from July 27, 2020, to July 28, 2020.You asked the Plan to pay forself-administered drugs under Medicare Part B. You say that this claim should be paid.The Plan denied your request. The Plan says payment for self-administereddrugs must be submitted to Medicare Part D.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 pay forself-administered drugs provided from July 27, 2020, to July 28, 2020.Benefits for self-administered drugs may be available under Medicare Part D.Contactthe 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 forcolonoscopy with polypectomy (45385) provided September 1, 2020.You asked the Plan to waive the copayment forthe colonoscopy with polypectomy. You say that you should not have to pay a copayment when this is part of your 10 year exam. This should be considered routine. You can see being charged for the biopsy but not for your routine 10 year exam.The Plan denied your request. The Plan says this 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 $150 copayment foreach ambulatory surgical center visit for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay $150 copayment foreach ambulatory surgical center visit for the colonoscopy with polypectomy. the colonoscopy with polypectomy 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 copayment forcolonoscopy with polypectomy (45385) provided September 1, 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) for the enrollee.
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 medical necessity for admission to acute inpatient rehab not 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for coronary artery bypass grafting and mitral and tricuspid valve replacements. Post operative
course was complicated by sepsis, wound infection, pneumonia, respiratory failure and COVID 19 infection.
Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex
nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical
record documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate
in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (77067 and 77063) provided on April 28, 2020.
You asked the Plan to pay for the digital breast tomosynthesis. You say that you would like reconsideration because the exam was billed twice in error. The Plan denied your request. The Plan says CPT 77067 and 77063 have an MUE value of 1 and provider billed 2 units.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 77067 and 77063 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for digital breast tomosynthesis (77067 and 77063) provided on April 28, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment foran ER visit provided form August 7, 2020, to August 8, 2020.You asked the Plan to waive the copayment foran ER visit. You say that you were admitted inpatient and should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.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 did not provide medical records. Without medical records we cannot determine whether or not you were admitted inpatient following the ER visit.Therefore, we decided that the Plan has to waive the copayment foran ER visit provided form August 7, 2020, to August 8, 2020.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
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shareforthe emergency care, observation care and Medicare Part B prescription drugs provided on January 16, 2020.You asked the Plan to waive thecost share forthe emergency care, observation care and Medicare Part B prescription drugs. You say that you are getting billed by the hospital.The Plan denied your request. The Plan says you were charged the copayments and coinsurance correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment forOutpatient Observation services andEmergency Care,and 20% coinsurance forMedicare Part B prescription drugs.You have been asked to pay a $90 copayment for Outpatient Observation services and Emergency Care, and 20% coinsurance for Medicare Part B prescription drugs. 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 thecost share forthe emergency care, observation care and Medicare Part B prescription drugs provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe Part B drug and specialist visit provided on July 31, 2020.You asked the Plan to waive the cost share forthe Part B drug and specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received Part B drugs and a specialist office visit on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs and a $40 copayment for specialist office visits.We looked at the file, the Plan's contract and Medicare rules. The file shows that you received Part B drugs on July 31, 2020. You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $1.18. The Part B drugs fall within the Medicare Part B prescription drugs benefit category. The file also shows that you received office visit services with a specialist on July 31, 2020. Youhave been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner services benefit category. This means that you have been asked to pay the correct amounts 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 cost share forthe Part B drug and specialist visit provided on July 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 5, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in a skilled nursing facility setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon July 20, 2020.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 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 physician's services providedon July 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay
provided from February 24, 2020, to March 17, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you would like this copayment
waived. The Plan denied your request. The Plan says the cost share has applied correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment for days 1-20 and a $100 copayment for days 21-100 for skilled nursing facility care.
The enrollee has been asked to pay a total cost share of $200 for days 21 and 22 of the SNF care. The service
provided falls within the skilled nursing facility care benefit category. This means that the enrollee has been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation the enrollee agreed to pay when the enrollee enrolled in the Plan. Therefore, we decided that the
Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay provided from February
24, 2020, to March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 21, 2020.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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. Thecontract 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 would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services providedon August 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided on July 31, 2020.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because multiple exams were rendered on the same date of service. The Plan denied your request. The Plan says CPT code 71045 is a column II procedure to the column I procedure, 32557.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the chest x-ray has a bundled relationship with code 32557 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71045) provided on July 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET scan (78815) provided.

You asked the Plan to pay for the PET scan. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. The rules say there is limited coverage for procedure code 78815 and ICD-10 Code C21.0 is not a covered diagnostic code for this service. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met.Therefore, we decided that the Plan does not have to pay for the PET scan (78815) provided.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy (45385) provided June 21, 2020.You asked the Plan to waive the copayment forthe colonoscopy. You say that you were advised that this procedure had no copay, You wouldn't have had this done if you knew there would be a cost. You only get $500 a month and cannot afford this.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $250 copay per visit, per provider, per day for surgery performed in an outpatient hospital setting. You have been asked to pay $250 copay for the colonoscopy. The colonoscopy falls within the Outpatient hospital services benefit category. This means that you have been asked to pay the correctamount 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 diagnostic colonoscopy (45385)provided June 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.

You asked the Plan to pre-approve SI joint injection. You say that there is no other source of help for your condition.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the documentation does not show conservative treatment within the past 6 months, or documentation that you have moderate pain with significant functional loss, pain unresponsive to outpatient medical management, inability to tolerate non-surgical care, or have had prior successful injections.

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 SI joint injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found SI joint injections are recommended as an option if the patient has failed at least 4 to 6 weeks of aggressive conservative therapy including physical therapy, home exercise, and medication management. In this case, there is insufficient documentation of conservative measures tried and failed. Your physical examination does not detail specifics regarding pain in the sacroiliac joint.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.