Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for a psychotherapy visit (90832) on November 20, 2020.
You asked the Plan to pay for a psychotherapy visit. You say that the requested services were medically
necessary for the enrollee. The Plan denied your request. The Plan says that rules for out of network care have
not been met.
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. The Plan has not disputed the medical necessity of the services at
issue. Based on this information, we decided that Medicare rules for coverage of a psychotherapy visit have
been met. Therefore, we decided that the Plan has to pay for a psychotherapy visit (90832) on November 20,
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 to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office services (CPT code 99213) provided to the
enrollee on January 8, 2021, by an out-of-network provider.

You asked the Plan to pay for the office services. You say that the claim should be paid. The Plan denied your
request. The Plan says this provider is out-of-network, the services were not referred by a network provider,
and the services were 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 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 the office services (CPT code 99213) provided to the enrollee on January 8, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiography (93306).
You asked the Plan to pre-approve a transthoracic echocardiography. You say that this request is medically necessary. The Plan denied your request. The Plan says that this request is not medically necessary because the member has no new signs or symptoms of heart disease.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a transthoracic echocardiography. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found a recent baseline assessment of left ventricular function to guide appropriate medical therapy in the future for her coronary artery disease and hypertension and also provide an ejection fraction baseline for any changes in function associated with progression of coronary artery disease is both reasonable and necessary for the chronic management of cardiovascular disease. This is especially true if, as in this case, it was severe enough to require coronary artery bypass graft revascularization. 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 transthoracic echocardiography have been met. Therefore, we decided that the Plan has to pre-approve a transthoracic echocardiography (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for TENS device (CPT code E0730) purchased on November 25, 2020.

You asked the Plan to reimburse for the TENS device. You say that you are requesting reimbursement for the purchase of the TENS device. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met. You are not enrolled in an approved clinical study. Therefore, we decided that the Plan does not have to reimburse for TENS device (CPT code E0730) purchased on November 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your record does not show that you require daily skilled nursing or
skilled therapy in a SNF setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on January 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that these services were provided at a skilled nursing facility. You say that it is the facility's responsibility to obtain prior authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the member's facility or the member's primary care physician.
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 skilled nursing services provided on January 17, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility visit provided by an out-of-network provider on September 8, 2020.
You asked the Plan to pay for the nursing facility visit. You say that the authorization for the facility should cover any services rendered to the patient while they are in the facility. You say that the services were provided in good faith and the claim should be processed for payment. The Plan denied your request. The Plan says utilization of in-network providers is required unless the plan pre-approves 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 nursing facility visit provided by an out-of-network provider on September 8, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 13 direct skilled nursing services of a RN (G0299 x13).
You asked the Plan to pre-approve the direct skilled nursing services of a RN. The Plan denied your request. The Plan says you have no skilled nursing needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.
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 direct skilled nursing services of a RN. Our reviewer says that these services are not medically necessary or reasonable. Our physician reviewer found you do not have any documented skilled nursing needs. 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 direct skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 13 direct skilled nursing services of a RN (G0299 x13).
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 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 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 considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on February 2, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that you thought the provider was in-network. You say you had a referral. The Plan denied your request. The Plan says the provider is out of network and a 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 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 the laboratory work provided on February 2, 2021 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on January 12, 2021.You asked the Plan to pay for the emergency department visit. 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 payable.
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 99284 for the emergency department visit has a bundled relationship with code 99285 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 emergency department visit coded 99284 provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. 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 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 considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current facility. Therefore, this request for LTACH services will be considered not
medically necessary at this time. Transfer to a lower level of care may be considered when treatment has
completed and the enrollee is more stable.

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 LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on April 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician visit. You say that you are appealing this denial. 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 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 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 a physician visit provided on April 14, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the panoramic x-ray provided on December 9, 2020.

You asked the Plan to pay for the panoramic x-ray. You say that this x-ray should be covered. The Plan denied your request. The Plan says that this procedure is covered once every 36 months.

The Plan must follow Medicare rules. The Medicare rules say that the health plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. 

We looked at the file and Medicare rules. The Plan denied this service for the panoramic x-ray benefit having been exhausted. The EOC does not clearly state that a panoramic x-ray specifically is limited to one x-ray every 3 years. You reasonably believed this service would be covered because panoramic x-ray is a covered service. Based on this information, we decided that the Plan's rules for coverage of the panoramic x-ray have been met. Therefore, we decided that the Plan has to pay for the panoramic x-ray provided on December 9, 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 to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate until you are stable to transfer to a lower level of care such as home with home health services or to a long term care facility.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a bilevel positive airway pressure
(BiPAP) device.

You asked the Plan to pre-approve BiPAP device. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of authorization for continued use of this device is correct,
because the record shows the enrollee has 0% of nights with over 4 hours of usage of this device and there is no
documentation of symptom improvement.

The Plan follows Medicare rules. Medicare rules state that continued use of a PAP device is only covered under
certain circumstances.

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 BiPAP device. Our reviewer says that
the enrollee does not meet the Medicare criteria for continued use of a BiPAP device. Our physician reviewer
found the enrollee has obstructive sleep apnea. The record indicates that the enrollee uses this device more than
4 hours per night 0% of the time. Therefore, the requested service is not recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of BiPAP device have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued use of a bilevel positive airway pressure (BiPAP) device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance angiography without contrast, of the chest (C8910) provided on August 31, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 each advanced imaging service.
You have been asked to pay a $275 copayment for the advanced imaging service provided. 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 magnetic resonance angiography without contrast, of the chest (C8910) provided on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit (99213, S9088) provided on February 13, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $65 copayment for each urgent care visit. You have been asked to pay a $50 copayment for the urgent care visit provided. This amount is the less than the applicable copayment for this service.
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 urgent care visit (99213, S9088) provided on
February 13, 2021.