Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 27, 2020.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for speech therapy services provided on December 21, 2020 and December 27, 2020.

You asked the Plan to pay for the speech therapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 speech therapy services provided on December 21, 2020 and December 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an X-Ray examination provided on December 11, 2020.

You asked the Plan to waive the coinsurance for X-Ray exam. You say that the prior authorization for this service permitted zero copayment. The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for out-of-network X-Rays. The allowed amount of the claim is $45.25, resulting in a coinsurance amount of $22.62. 

You have been asked to pay 50% coinsurance for X-Ray exam. X-Ray exam falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 X-Ray examination provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluation services provided on September 7, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the interrogation device evaluation 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 payable.

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 interrogation device evaluation services provided on September 7, 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 dermatology services provided on December 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the dermatology 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 a covered benefit.
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 dermatology services provided on December 7, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the post-operative services provided on December 9, 2020.

You asked the Plan to pay for the post-operative services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says these services are included in the global surgical package.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that the post-operative services provided are not separately payable. Specifically, post-operative visits performed during the postoperative period of a global surgery that are related to the recovery from that surgery are included in the global surgical package. Based on this information, we decided that Medicare rules for coverage of the post-operative services have not been met. Therefore, we decided that the Plan does not have to pay for the post-operative services provided on December 9, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 20, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you feel that you are paying too much for copayments. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $155 copayment for reach radiological diagnostic service. 

You have been asked to pay a $155 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic tests and therapeutic services and supplies 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 ultrasound provided on November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non emergent ambulance transport to doctor's visits.

You asked the Plan to pre-approve non emergent ambulance transport to doctor's visits. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non emergent ambulance transport to doctor's visits. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation does not indicate that you require the services of a fully equipped ambulance. The documentation does not establish that other modes of transportation are contraindicated. The documentation does not establish the medical necessity or reasonableness of the requested service as defined by Medicare rules. The elements of the coverage rule are not satisfied. Therefore, you do not meet criteria for the requested 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 non emergent ambulance transport to doctor's visits have not been met. Therefore, we decided that the Plan does not have to pre-approve non emergent ambulance transport to doctor's visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the methylprednisolone 40mg acetate
injection (J1030) provided on December 30, 2020.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance 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 15% of
the total cost for Medicare-covered Part B prescription drugs, including chemotherapy drugs.

You have been asked to pay $1.85 (Plan allowed amount of $12.35 x 15% coinsurance) for the
methylprednisolone injection 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 coinsurance for the
methylprednisolone 40mg acetate injection (J1030) provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 services provided on June 1, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a powered pressure-reducing air mattress is
covered when specific criteria are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you do not have
multiple stage two pressure ulcers on the trunk or pelvis that have failed to improve over the past month, during
which you have been on a comprehensive ulcer treatment program. You do not have a muscle/skin flap or skin
graft for a pressure ulcer on the trunk or pelvis within the past 60 days. The requested mattress is therefore not
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a powered pressure-reducing air mattress.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy, initial assessment and
intervention, individual, face-to-face with the patient, each 15 minutes (97803) provided March 5, 2020, to
November 11, 2020.
You asked the Plan to pay for medical nutrition therapy services. You say that you spoke to the plan and was
advised that you had this service 1 time per month. They have not been paid. The Plan denied your request. The
Plan says the enrollee does not meet the criteria as the provider notes indicated the enrollee has weight gain and
high cholesterol and there is no documentation of diabetes, renal disease or a renal transplant.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does
not have to pay for the medical nutrition therapy, initial assessment and intervention, individual, face-to-face
with the patient, each 15 minutes (97803) provided March 5, 2020, to November 11, 2020.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay 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 considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent nephroureteroectomy, radical cystectomy, and hepaticojejunostomy. The enrollee continues to receive acute care services that have not been denied. The enrollee does not currently require services that they are unable to receive that the acute care facility that would be available at the LTACH facility. The elements of the coverage rule are not satisfied. The requested service cannot be 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 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 the office visit (99214) provided on November 13, 2020.

You asked the Plan to pay for the office visit. You say that you would like reconsideration because this service
was not post-operative. The Plan denied your request. The Plan says this service was not billed with the
appropriate modifier indicating that the denied service was unrelated and rendered during the post-operative
period of a global procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99214 is not supported in the record. Specifically, this claim was not billed with the
required modifier to indicate that this service was unrelated. Based on this information, we decided that
Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not
have to pay for the office visit (99214) provided on November 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture provided on November 11, 2020.

You asked the Plan to pay for the maxillary partial denture. You say that you would like to appeal this service. The Plan denied your request. The Plan says you have already been reimbursed for the full amount of the dental allowance for non-Medicare covered dental services.

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 Plan offers a $2,000 dental allowance every year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit on October 20, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the maxillary partial denture provided on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 20, 2020.

You asked the Plan to pay for the lab services. You say that you have no knowledge of the enrollee's coverage prior the specimen's arrival at the lab. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We looked at the file and the rules. In this case, there is no indication the enrollee's sample was taken at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a not medically necessary vision service (Opti-map) (S9986)
provided on January 26, 2021.
You asked the Plan to pay for the vision service. You say that you were told these services should be covered.
The Plan denied your request. The Plan says this service is not covered by the Plan or by Medicare. The Plan
has provided reimbursement for the eye exam and refraction; however, the provider's office also performed an
Opti-map screening. In a call to the provider, the Plan found that you were advised this procedure may not be
covered by insurance.
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 only covers a routine eye exam and refraction. An Opti-mapping procedure is not listed as a
covered service.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pay for a not medically
necessary vision service (Opti-map) (S9986) provided on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says the criteria requirements were not 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 the monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee is not using insulin. There is no indication why using a glucometer would not suffice.

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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic exam cancer screening provided on January 4, 2021.
You asked the Plan to pay for the pelvic exam cancer screening. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says your previous exam was on December 4, 2019 and you do not have high risk factors.
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 pelvic exam cancer screening. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found guidelines recommend cytology every 3 years or co-testing with cytology and HPV every 5 years for routine screening. You have no risk factors for cervical cancer. Therefore, you are not due for a pap smear until January 4, 2021, both in terms of her insurance coverage and in terms of medical 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 the pelvic exam cancer screening have not been met. Therefore, we decided that the Plan does not have to pay for the pelvic exam cancer screening provided on January 4, 2021.