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

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary due to a change in firmness at the lumpectomy site and to rule out recurrence of cancer. The Plan denied your request. The Plan says that the information provided does not support the need for MRI services.
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 of the breast is medically reasonable and necessary. Our physician reviewer found the enrollee was diagnosed with stage I breast cancer in 2012 and treated with lumpectomy. Screening mammography in February 2020 was normal. On examination June 18, 2020, there was documented change in the physical exam of the lumpectomy site with increased firmness. The enrollee has a recent normal mammogram which was inconsistent with physical examination findings. 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) services.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide 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 pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan
denied your request. The Plan says the requested LTACH care is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee's
ongoing care needs include wound care, intravenous antibiotics, surveillance laboratory studies, fluid balance,
and therapy services. The documentation does not support that the enrollee in this case requires services at the
LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
required medical services identified that are available at the LTACH, that are not available at the current health
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on August 26, 2019. 
 
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that you were not informed clearly as to why this bill is $40. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered specialist office visit.  
 
You have been asked to pay a $40 copayment for the comprehensive hearing test. The comprehensive hearing test 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 the comprehensive hearing test provided on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain crown (D2740) provided on February 27, 2020.
You asked the Plan to pay for the porcelain crown. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says a porcelain crown is not a covered
benefit under your contractual policy.
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, a porcelain crown is not among those
items/services covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
porcelain crown (D2740) provided on February 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that the requested services are
medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower
level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health services.
Our reviewer says that the inpatient level mental health services are not medically necessary. Our physician
reviewer found that based upon review the records provided, this enrollee does not require acute inpatient
psychiatric hospitalization treatment and could be treated in a lesser restrictive setting as she was not a danger
to herself or others, and was not showing any psychosis, aggressive behaviors, or perceptual disturbance
including auditory or visual hallucinations.
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 inpatient mental health services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health care stay provided from September 25, 2019 to October 2, 2019. 
 
You asked the Plan to waive the copayment for the inpatient mental health care. You say that you cannot afford to pay the balance owed. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment per day, days 1-5 and a $0 copayment per day, days 6-90 for each medically necessary covered innetwork mental health inpatient stay.  
 
You have been asked to pay a $295 copayment for each day, days 1-5, of the inpatient mental health care. ($295 x 5 = $1,475). The inpatient mental health care falls within the "Inpatient mental health 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 mental health care stay provided from September 25, 2019 to October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (77525). 
 
You asked the Plan to pre-approve PBRT. You say that the services are 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. 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 PBRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not adequately document, using quantifiable dosimetric measures, that an intensitymodulated radiation therapy (IMRT) or conventional 3D conformal plan would be unacceptable. It would therefore not be furnished in accordance with accepted standards of care using NCCN guidelines and ASTRO model policy. As such, proton therapy is not medically necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) (77525).
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 you would like reconsideration because the IRF
admission is medically necessary. The Plan denied your request. The Plan says your care may be safely
provided in a lower level of care.
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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 12, 2019 by a non-contracted provider. 
 
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 the services were rendered by a non-contracted provider without 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 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 February 12, 2019 by a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for (A7035), (A7030), (A7031), (A7038),
(A4604) and (A7046) provided on December 19, 2019 by an in-network provider.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share
responsibility for the services you received. 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 show that you received the DME on December 19, 2019. You are asked to pay 20%
coinsurance for each DME. 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 (A7035), (A7030),
(A7031), (A7038), (A4604) and (A7046) provided on December 19, 2019 by an in-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99348) provided on August 15, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the billed code does not appropriately reflect the
services provided.
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 99348 is home visit for the evaluation and management
of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused
interval history; An expanded problem focused examination; Medical decision making of low complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent face-to-face
with the patient and/or family.
We asked our coder 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 home visit. Our reviewer says that CPT code 99348 does
not meet criteria for billing or reimbursement consideration. Our reviewer found Code 99348 is a physician or
other qualified provider reporting code. Registered Nurse is not considered a qualified provider for this code. In
order for this code to be billable, a physician, or other qualified provider is required to be in the home.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the home visit have not been met. Therefore, we decided that the Plan does not
have to pay for a home visit (99348) provided on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an eye injection provided by a
participating provider on January 28, 2020.
You asked the Plan to waive the coinsurance for an eye injection. You say that you never had this issue when
you had your old insurance plan. You say that this shouldn't be billed as a surgery because it is just an injection.
The Plan denied your request. The Plan says the correct coinsurance 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 20%
coinsurance for Medicare Part B drugs/in-network.
You have been asked to pay a 20% coinsurance of the allowed amount for an eye injection. The total allowed
amount is $1,904.94. The total amount you are being asked to pay is $380.99 ($1,904.94 x 20% = $380.99). An
eye injection falls within the Medicare Part B drugs/in-network 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 an eye injection provided by a participating provider on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional chiropractic visits.
You asked the Plan to pre-approve 9 additional chiropractic visits. You say that chiropractic treatment makes
your pain tolerable. The Plan denied your request. The Plan says this treatment has not improved your
condition.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance
care.
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 9 additional chiropractic visits. Our
reviewer says that the requested services are non-covered maintenance care. Our physician reviewer found the
records show that your initial complaint was of back pain, rated at 6/10, and, after 20 visits, your back pain was
rated at 7/10. You continue to have moderate problems with walking, sitting and lifting. You have constant
flare-ups of upper back pain and arm pain, aching neck and low back stiffness. There is no evidence in the
submitted documentation that clinical improvement has occurred or that further clinical improvement can
reasonably be expected from continued treatment. The treatment is considered maintenance therapy and is not
supported or allowed per Medicare guidelines.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 9 additional chiropractic visits have not been met. Therefore, we decided that
the Plan does not have to pre-approve 9 additional chiropractic visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the retrobulbar injection provided on October 23, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that this should not be denied as inclusive to any other procedures as these procedures are done by different providers and these claims are always paid by Medicare without the need to appeal. The Plan denied your request. The Plan says that codes for ophthalmic injections shall not be reported separately with other ophthalmic procedures codes when the injected substance is an anesthetic.
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. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of 67500 have been met. Specifically, this service was rendered by a provider different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the retrobulbar injection provided on October 23, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in bathtub. 
 
You asked the Plan to pre-approve the bathtub. You say that the walk-in bathtub is medically necessary. The Plan denied your request. The Plan says the walk-in bathtub is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in bathtub.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of INR test materials rendered on December 23, 2019 to December 30, 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 the services are not allowed more frequently than once every four weeks.
The Plan must follow Medicare rules. The rules say that procedure code G0249 shall not be allowed more frequently than once every four weeks. We looked at the file and Medicare rules. The file shows that procedure code G0249 was billed less than four weeks from the previously approved claim. 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 provision of INR test materials rendered on December 23, 2019 to December 30, 2019.