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

We decided that the Plan does not have to pay for the Human Papilloma Virus vaccine provided on February 5, 2021.
You asked the Plan to pay for the Human Papilloma Virus vaccine (90651). You say that you want the Plan to consider covering all three shots of this vaccine. The Plan denied your request. The Plan says the vaccine is a Medicare Part D medication.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Human Papilloma Virus vaccine (90651). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Human Papilloma Virus vaccine (90651). Therefore, we decided that the Plan does not have to pay for the Human Papilloma Virus vaccine provided on February 5, 2021.
Benefits for the Human Papilloma Virus vaccine (90651) 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: 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 need rehab to help you regain your strength back. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 were admitted for aortic valve replacement
surgery. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport services received on January 29, 2021.

You asked the Plan to pay for the ambulance response and treatment, no transport services. 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 Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services on January 29, 2021. 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 response and treatment, no transport services received on January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on January 14, 2021.

You asked the Plan to pay for an electrocardiogram. You say that this code is supported. The Plan denied your request. The Plan says this code cannot be paid as billed.

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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.

We find that CPT code 93010 is not supported in the medical record. Specifically, the submitted medical records did not include documentation of an interpretation and report of the ECG. Based on this information, we decided that Medicare rules for coverage of an electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca (Q5111).
You asked the Plan to pre-approve Udenyca. You say that you would recommend Udenyca to be added to the
enrollee's regimen. The Plan denied your request. The Plan says there is no indication that the enrollee has tried
the formulary alternatives, or has any adverse effects.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Udenyca. Our reviewer says that
Udenyca is not medically reasonable and necessary for the enrollee. Our physician reviewer found based on the
medical records provided the enrollee has not tried and failed the required drug, Zarxio. Our reviewer also
found that there is no indication that the Plan's required drug would likely be less effective and/or likely have
adverse effects for the 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 Udenyca have not been met. Therefore, we decided that the Plan does not have
to pre-approve Udenyca (Q5111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided March 2, 2021.
You asked the Plan to pay for the eye refraction. You say that this provider is contracted with the Plan's network and should be covered. The Plan denied your request. The Plan says the provider is not part of the Plan's third-party vision vendor's routine vision network and therefore the service is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services during a routine eye exam when performed by a routine vision care provider who is part of the Plan's third-party vision vendor's network. We looked at the file and the Plan's rules. The provider who rendered the services is not a participating routine vision provider in the Plan's third-party vision vendor's network. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Lumbar-sacral orthosis (L0651), provided on January 26, 2021.
You asked the Plan to pay for Lumbar-sacral orthosis. You say that the item was medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. The ordering physician was not the provider who evaluated the enrollee. Therefore, we decided that the Plan does not have to pay for Lumbar-sacral orthosis (L0651), provided on January 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on April 19, 2021.
You asked the Plan to waive the copayment for eye exam. You say that you think you are being charged extra for this exam. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $35 copayment for eye exam. You have been asked to pay $35 copayment for eye exam. Eye exam falls within the Vision Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye examination provided on April 19, 2021.
If the provider has charged you any amount beyond the applicable cost-sharing for this visit, please contact the Plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on
February 3, 2021, through February 26, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not have to pay
the copayment because of the conditions of the hospital. The Plan denied your request. The Plan says the cost
share was 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 a $275
copayment each day for days through five for inpatient hospital care.
You have been asked to pay a $275 copayment each day for days through five for inpatient hospital care.
inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been
asked to pay the correct amount based on your contract with the Plan ($275 x 3 days = $825). 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 inpatient hospital care provided on February 3, 2021, through February 26, 2021.
Your complaint about the conditions of the hospital is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from September 17, 2020 to October 28, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the number of units do not correspond with the date span.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services must be reported correctly. The file shows that there were 41 days of inpatient mental health services. However, 42 days were billed, which is incorrect billing. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided to the enrollee from September 17, 2020 to October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and the intraoral - periapical first radiographic image (D0220) received February 25, 2021.
You asked the Plan to pay for the limited oral evaluation and the intraoral radiographic image. You say that you did not receive the x-ray. The Plan denied your request. The Plan says the requested services are not covered by your supplemental benefit. Therefore, no reimbursement can be provided.
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 for the limited oral evaluation - problem focused (D0140) and the intraoral - periapical first radiographic image (D0220) received February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) received April 1, 2021.
You asked the Plan to pay for the intraoral complete series of radiographic images. You say that you did not ask for the x-rays. The Plan denied your request. The Plan says the requested service is not covered under your supplemental benefit.
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 for the intraoral - complete series of radiographic images (D0210) received April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 25, 2020.
You asked the Plan to pay for the critical care 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the submitted medical records document only 15 minutes of critical care time. A minimum of 30 minutes or more are required to bill this code. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on May 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on January 6, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no clinical rationale for the obtained lab studies. The review has determined that the laboratory services provided to the enrollee on January 6, 2021 were not medically reasonable or necessary.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on December 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the debridement. You say that the ordering physician's office failed to obtain the referral and you should not be penalized. The Plan denied your request. The Plan says no prior authorization was 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 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 debridement provided on December 28, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary-level referral to an ophthalmologist.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's condition can be managed at a lower level of care.
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 the referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that a diagnosis of iridiocyclitis due to corneal abrasion. You have requested this referral. The provided medical records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary-level referral to an ophthalmologist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram services coded 93010 provided on January 5, 2021.
You asked the Plan to pay for the electrocardiogram services. You say that you disagree with the plan's 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, the CPT Code Manual definition of code 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, this code was billed on the same date of service with an emergency department visit. The provider of this service and the provider of the
emergency department visit have the same specialty of emergency medicine. In addition, there is no documentation for an interpretation by the rendering provider. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram services coded 93010 provided on January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral pap device (E0486), to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve an oral pap device. You say that it is cheaper to go to the out-of-network
provider. The Plan denied your request. The Plan says they have in-network providers available to provide this
service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an oral pap device (E0486), to be provided by an out of network (OON) provider.