Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or home with outpatient therapy.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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program.Welooked 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the dialysis services rendered on December 2, 2019 to December 4, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the claim should be paid the Plan at 100 percent. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for kidney dialysis.
Review of the file shows that you received dialysis from December 2, 2019 to December 4, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $162.89. These services fall within the kidney dialysis 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 the dialysis services rendered on December 2, 2019 to December 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the service is 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. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found while it would be convenient for the enrollee to have the requested MRI of the lumbar spine prior to seeing the spinal doctor the criteria for establishing medical necessity of the requested MRI of the lumbar spine are not yet met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain crown (D2740) for tooth # 20 provided on January 22, 2020.You asked the Plan to pay forthe dental service. You say that you lost your crown while eating. You say that if it is not replaced, the tooth will deteriorate further and create other, more serious problems.The Plan denied your request. The Plan says crowns are covered once per tooth every 5 plan years. The Plan also says that the frequency limit has been exceeded for this tooth.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 and crowns are a covered service, the frequency limit per tooth has been exceeded. The record shows that the Plan paid for a crown for tooth # 20 that you received on February 3, 2016.Therefore, we decided that the Plan does not have to pay forthe porcelain crown (D2740) for tooth # 20 provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on March 10, 2020. 
 
You asked the Plan to pay for the panoramic x-ray. The Plan denied your request. The Plan says this procedure is covered once every 36 months. The Plan also says that you are not eligible for another panoramic x-ray until after August 16, 2021. 
 
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, full mouth x-rays are limited to once every 3 years. The record shows that you received a panoramic x-ray on August 16, 2018 and your full mouth x-rays benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacupuncture.You asked the Plan to pre-approveacupuncture.. 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 a covered benefit.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90 period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture is not covered under your plan benefit. Therefore, we decided that the Plan does not have to pre-approveacupuncture.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe office visit (99202) and extremity study (93970) provided on September 30, 2019.. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the enrollee did not meet criteria to receive out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We foundno exception that would require the Plan to pay for these items/services. Additionally, the documentation submitted does not include medical records to verify if the services were urgent or emergent.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 30, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 25, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that the ordering provider told you that they accepted
your insurance. The Plan denied your request. The Plan says the denial of payment for these services 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 has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on October 25, 2019
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory tests provided on January 16, 2020.
You asked the Plan to pay for lab tests. You say that your lab performed all the tests that were ordered by the
referring physician. The Plan denied your request. The Plan says the denial of payment for these services is
correct, because these tests are not a Medicare benefit for the diagnoses listed and were performed for
screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered. The rules say that a physician order or clear intent to order specific lab
services is required for covered lab services. The documentation submitted does not include a valid physician order or clear intent to order the specific lab
services billed on this claim to show that these tests were ordered for non-screening purposes. Based on this
information, we decided that the Medicare criteria for lab tests have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory tests provided on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 precision attachments (D5862), the connecting bar (D6055), the H2Ocean 16 ounce (D9999), the surgical set up (D9999), and 2 gingivectomy or gingivoplasty (D4212) provided from June 25, 2019 to September 20, 2019. 
 
You asked the Plan to pay for the dental services. You say that you had oral mouth cancer surgery in August 2016. You say that you were advised by a plan representative that the services you received are considered medical services. You also say that you have spoken with multiple representative that have been unable to have the claims paid. The Plan denied your request. The Plan says the services you received are not covered under your medical coverage. The Plan says that the implants and restorative services that you received were not performed in preparation for radiation treatments for neoplastic disease. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for 2 precision attachments (D5862), the connecting bar (D6055), the H2Ocean 16 ounce (D9999), the surgical set up (D9999), and 2 gingivectomy or gingivoplasty (D4212) provided from June 25, 2019 to September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit provided on February 8,2020.You asked the Plan to waive the deductible forthe office visit. You say that you have been to the clinic before without any issues. You say that the bill is beyond your ability to pay.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. Out-of-network services are not excluded from the deductible.The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network office visit was received on February 8, 2020.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on February 8, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on September 19,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 97163 is not supported.
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 97163 is physical therapy evaluation, high complexity,
typical time with patient and/or family 45 minutes.
We find that CPT code 97163 is not supported in the medical record. Specifically, there is no documentation of
a physical therapy evaluation for the date of service at issue. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the physical therapy services rendered on September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Novolog 100 unit/ml vial.You asked the Plan to pre-approve a tier exception for Novolog 100 unit/ml vial. You say that the exception is needed.The Plan denied your request. The Plan says Part B medications do not qualify for tier exceptions.The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Novolog 100 unit/ml vial have not been met. Specifically, the requested drug is covered under Medicare Part B. This means that it is not eligible for a tier exception, as Medicare Part B Drugs are not subject to tier exceptions.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Novolog 100 unit/ml vial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on February 25, 2020.You asked the Plan to waive the copayment for a colonoscopy. You say that you were quoted varies amounts but were not informed that you would owe a $600 copayment.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 $600 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $600 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora colonoscopy provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Group 3 power wheelchair power seat elevation feature
or liftgate service.
You asked the Plan to pre-approve a power seat elevation feature, and liftgate service. You say that you are
aware the power seat elevation feature and liftgate service are not covered by Medicare or the Plan. The Plan
denied your request. The Plan says power seat elevation features and vehicle wheelchair lifts are not covered
by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve Group 3 power wheelchair power seat elevation feature or
liftgate service.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for wound debridement and compression system application provided from December 3, 2019 through February 11, 2020. You asked the Plan to reduce the copayment for wound debridement and compression system application. You say that you were prepared to pay a $40 copayment per visit. You say that you are unable to afford these amounts. The Plan denied your request. The Plan says the copayments 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 $350 copayment per date of service for outpatient surgery at an out-of-network outpatient hospital facility and a$375 copayment per date of service for outpatient surgery at a preferred outpatient hospital facility. You have been asked to pay a total of $2,040.80 for the wound debridement and compression system application. Wound debridement and compression system application fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The wound debridement and compression system application are considered surgical services that were provided by the hospital. The records show that you have no member liability for the clinic visit on February 11, 2020. 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 reduce the copayment for wound debridement and compression system application provided from December 3, 2019 through February 11, 2020.
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 care can be received in another setting.
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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from July 17, 2019 to July 29, 2019.
You asked the Plan to pay for the inpatient services. You say that the enrollee was not enrolled in hospice care at the time of the service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 2, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from July 17, 2019 to July 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services provided on September 5, 2018 by an out of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 5, 2018 by an out of network (OON) provider.