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

We decided that the Plan does not have to waive the copayment forradiologic examination, knee (73564) provided August 25, 2020.You asked the Plan to waive the copayment forthe x-ray services. You say that this was for an x-ray for confirming diagnosis of a knee injury. The doctor's telehealth visit was covered in full but this was not. You think that both should be covered.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 copay for services performed by a provider other than your primary care physician. You have been asked to pay $44.32 x-ray services. Since the approved amount was less than the $50 copay, the balance is your responsibility. The x-ray services fall 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 forradiologic examination, knee (73564) provided August 25, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient diagnostics provided on August 12, 2019.You asked the Plan to pay for the outpatient diagnostics. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available andrequires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, 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 outpatient diagnostics. 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 outpatient diagnostics provided on August 12, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. 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 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 does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
clavicular fracture, rib fractures and deep vein thrombosis. Medical conditions are stable. There are no medical 
needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational 
therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable 
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization provided from January 18, 2018, through
January 19, 2018.
You asked the Plan to pay for post stabilization. You say that the services were medically necessary. The Plan
denied your request. The Plan says the enrollee's emergency medical condition stabilized in the ED by 5:50 pm
on January 18, 2018, and subsequent care was post stabilization care, not approved in compliance with the
health plan's authorization procedures.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 post stabilization. Our reviewer says that the
service is not medically necessary. Our physician reviewer found the documentation did not show any evidence
suggesting the patient was not stable to transfer.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of post stabilization have not been met. Specifically, prior authorization was not
obtained before providing services once the enrollee was stable for transfer. This means the services are not
coverd. Therefore, we decided that the Plan does not have to pay for post stabilization provided from January
18, 2018, through January 19, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 30, 2020.
You asked the Plan to pay for limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you have exceeded the Plan's frequency limitation for this service.
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. Specifically, records indicated you received this service on September 17, 2020. This means you have already exhausted the maximum frequency limitation making this a non-covered service. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on September 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment and abutment supported 
porcelain fused to metal crown provided on September 29, 2020. 
 
You asked the Plan to pay for the custom fabricated abutment and abutment supported crown. You say that 
your statement of benefits says that a crown after a tooth replacement is covered. The Plan denied your request. 
The Plan says any services associated with dental implants are not covered by your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
custom fabricated abutment and abutment supported porcelain fused to metal crown provided on September 29, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid services provided on July 7, 2020, August 1, 
2020 and August 21, 2020. 
 
You asked the Plan to pay for hearing services. You say that the services should be covered. The Plan denied 
your request. The Plan says prior authorization must be obtained for hearing services. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only when received by a Medicare participating provider with prior authorization. 
 
We looked at this physician's review, the file, and the Plan's rules. Based on this information, we decided that 
the Plan's rules for coverage of hearing services have not been met. Specifically, you did not receive prior 
authorization or use a Medicare participating provider. This means the services are not covered. Therefore, we 
decided that the Plan does not have to pay for hearing aid services provided on July 7, 2020, August 1, 2020 
and August 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Transcranial Magnetic Stimulation visits (CPT Code(s): 
90867, 90869 and 90868). 
 
You asked the Plan to pre-approve the visits. You say that the services are medically necessary. You state the 
enrollee has tried and failed at least eight (8) antidepressants. The Plan denied your request. The Plan says there 
continues to be a lack of evidence of sufficient treatment failures with standard treatments, and criteria are not 
met for coverage of TMS. 
 
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 visits. Our physician reviewer found 
based on the information provided, this enrollee does not meet the clinical criteria for the use of TMS therapy 
utilizing LCD (L34522). Documentation presented does not show the enrollee to be at the minimum effective 
dose as no doses for the medications was provided. This enrollee does not meet the criteria as outlined by the 
LCD requirement for Transcranial Magnetic Stimulation (TMS) and is therefore not considered 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 the visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Transcranial Magnetic Stimulation visits (CPT Code(s): 90867, 90869 and 90868).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional thirty-eight (38) miles. 
 
You asked the Plan to pre-approve additional miles. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says additional miles above your benefit allowance of 50 
miles are not covered by Medicare or your health plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. The 51st mile and beyond is not a covered 
benefit. Each one-way trip must not exceed fifty (50) miles of driving distance. A trip is one-way 
transportation; a round trip is two (2) trips. Therefore, we decided that the Plan does not have to pre-approve an 
additional thirty-eight (38) miles.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating hospital on September 25, 2020. 
 
You asked the Plan to waive the copayment for an outpatient surgery. You say that you were told that your 
copayment would be $150. The Plan denied your request. The Plan says the correct copayment 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 $210 
copayment for outpatient surgery.  
 
You have been asked to pay a $210 copayment for an outpatient surgery. The correct copayment has been 
applied to the services that were provided. An outpatient surgery falls within the outpatient surgery 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 outpatient surgery provided by a 
participating hospital on September 25, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 24, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 28, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on April 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forpanoramic radiographic image (x-ray) (D0330) provided on September 23, 2020.You asked the Plan to pay forpanoramic x-ray. You say that the service should be covered.The Plan denied your request. The Plan says the services exceed the frequency limitation in the benefit planMedicare 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. Specifically, records indicate you received this service January 31, 2019. This means you have already exhausted the three-yearmaximum frequency allowed for this service.Therefore, we decided that the Plan does not have to pay forpanoramic radiographic image (x-ray) (D0330) provided on September 23, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin assay (84591) provided on July 6, 2020.
You asked the Plan to pay for a vitamin assay. You say that this is a covered service. The Plan denied your
request. The Plan says this is considered a non-covered screening service.
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 a vitamin assay. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found no documentation has been submitted to support the indication for this test.
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 vitamin assay have not been met. Therefore, we decided that the Plan does not
have to pay for a vitamin assay (84591) provided on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH 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 determineif the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided necessitating admissionto a LTACH. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital whereshe is currently receiving care. 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.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-approvelong-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says medical conditions are well controlled.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis and an intra-abdominal abscess. Medical conditions are stable. There are no medical needs requiring inpatient admission. 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. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 8, 2020 by an out 
of network provider. 
 
You asked the Plan to pay for the physician services. You say that your provider retired so you went to this 
provider. The Plan denied your request. The Plan says you did not request 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 had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 
at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided 
that the Plan does not have to pay for the physician services provided on October 8, 2020 by an out of network 
provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveepidural steroid injections (62321).You asked the Plan to pre-approvethe epidural steroid injections. You say that the injection is medically necessary.The Plan denied your request. The Plan says that there was insufficient conservative treatment.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 the epidural steroid injections. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has uncontrolled pain and clear abnormal neurologic findings. The epidural is an attempt to avoid surgery and is medically appropriate.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 epidural steroid injections have been met.Therefore, we decided that the Plan has to pre-approveepidural steroid injections (62321).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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transforaminal epidural steroid injection for the enrollee.You asked the Plan to pre-approvethe injection. You say that this is medically necessary.The Plan denied your request. The Plan says basic imaging is required before treatment.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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of recent imaging. The lackof imaging does not meet the LCD criteria; therefore, the request is deemed 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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea transforaminal epidural steroid injection for the enrollee.