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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and
pelvis (74176) and a CT scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and a CT scan of the chest. You say
that the services are necessary. The Plan denied your request. The Plan says based on the documentation
provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen and pelvis
and a CT scan of the chest. Our reviewer says that the services are not medically necessary. Our physician
reviewer found there are no reports of prior imaging studies to indicate the timing or findings of prior scans.
Without such documentation the medical necessity of a CT of the chest, abdomen and pelvis is not established.
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 CT scan of the abdomen and pelvis and a CT scan of the chest have not been
met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of
the abdomen and pelvis (74176) and a CT scan of the chest (71250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a FreeStyle Libre therapeutic continuous glucose monitor (CGM) and sensors provided on December 3, 2020.
You asked the Plan to pay for therapeutic CGM. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the documentation submitted does not sufficiently document the enrollee's medical condition to support the medical necessity of the billed items.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for a FreeStyle Libre therapeutic continuous glucose monitor (CGM) and sensors provided on December 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the litholapaxy provided on July 6, 2020.
You asked the Plan to waive the copayment for the litholapaxy. You say that you were charged too late, and you do not feel like you should have to pay this amount. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $350 copayment for each Medicare-covered outpatient hospital visit, after you meet your $250 deductible. You have been asked to pay a $350 copayment for the litholapaxy. The litholapaxy falls within the "Outpatient hospital services" 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 the litholapaxy provided on July 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to
the enrollee from April 27, 2021, forward.
You asked the Plan to pre-approve inpatient mental health 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 inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient mental health care. Our
physician reviewer found the health plan's denial of continued inpatient psychiatric services appears
appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as
noted above as the enrollee was not a danger to themself or others and did not have any delusions, auditory or
visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did
not appear that the services for the dates in question were reasonably expected or medically necessary to
improve the enrollee's condition or for the purpose of diagnosis. Our physician reviewer was unable to find an
individualized treatment plan however the entire record is not present. It appears that the services were
supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet
the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of April 26,
2021, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any
suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors
or aggression being cooperative and compliant while not showing any acute threats to safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from April 27, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the paravertebral facet joint injections provided on November 11, 2020.
You asked the Plan to waive the copayment for the paravertebral facet joint injections. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $225 copayment for Outpatient Surgery ambulatory surgical center visit. You have been asked to pay a $225 copayment for the paravertebral facet joint injections. The paravertebral facet joint injections fall within the Outpatient Surgery Ambulatory Surgical Center Visit 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 the paravertebral facet joint injections provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 18, 2020.
You asked the Plan to pay for the physician service. You say that the service was medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 physician services provided on November 18, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of extracranial arteries (93880) provided on December 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the duplex scan. You say that at the time of service, an authorization was not obtained. You believe the enrollee was admitted for medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 duplex scan of extracranial arteries (93880) provided on December 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) provided January 26, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you went to see an orthopedic surgeon on the 19th because you had a splinter removed from your hand. You saw the assistant for less than 5 minutes and she charged you another $45 copay. You don't think it is right to charge that. The Plan denied your request. The Plan says the 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 $45 copayment for each in-person specialist visit. You have been asked to pay $45 copayment for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visits 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 the outpatient office visit (99212) provided January 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-one.
You asked the Plan to pre-approve Gel-one. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be 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 Gel-one. Our reviewer says that the services are not medically necessary. Our physician reviewer found the coverage criteria requires a trial of physical therapy; lacking this documentation, the request is considered 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 Gel-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-one.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0140, D7210) provided December 15, 2020.
You asked the Plan to pay for the dental services. You say that these services were medically necessary. The Plan denied your request. The Plan says the dentist that performed these services is not eligible for Medicare payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for dental services (D0140, D7210) provided December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (resin-based composite) (D2391) provided on
January 15, 2020 and the unspecified preventative procedure (D1999) and miscellaneous drug (Periogard)
(A9150) provided on September 4, 2020.
You asked the Plan to pay for the dental services. You say that you cannot afford this bill and would appreciate
if the Plan would use the full $300 maximum to cover these services. The Plan denied your request. The Plan
says they can only cover some preventative dental services. All of the requested services fall under the
comprehensive dental category and are therefore not covered by Medicare or by the 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 filling
(resin-based composite) (D2391) provided on January 15, 2020 and the unspecified preventative procedure
(D1999) and miscellaneous drug (Periogard) (A9150) provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractor services rendered from August 12, 2020 to August 26, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted claims for procedure codes 99203 (office visit), 97012 (mechanical traction therapy), 97014 (electrical stimulation), and 98943 (extraspinal manipulation). These services are not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for the chiropractor services rendered from August 12, 2020 to August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330), complete series of radiographic images (D0210) and unspecified preventative procedure, by report (D1999) provided December 5, 2020.
You asked the Plan to pay for the panoramic x-rays, complete series of x-rays and unspecified preventative procedure. You say that you were not told the x-rays would not be covered and cannot afford the bill. The Plan denied your request. The Plan says the EOC does not show any coverage for these benefits.
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 panoramic radiographic image (D0330), complete series of radiographic images (D0210) and unspecified preventative procedure, by report (D1999) provided December 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on December 23, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the services provided to you by an out-of-network provider on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 4, 2020 by a non-participating 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 a non-participating 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on November 4, 2020 by a non-participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an orthosis (L0650) provided August 18, 2020.
You asked the Plan to pre-approve the orthosis. You say that the orthosis was medically necessary. The Plan denied your request. The Plan says this DME was furnished as the result of an unsolicited phone call and is not covered.
The Plan must follow Medicare rules. Medicare rules say that a supplier of a covered item of durable medical equipment (DME) may not contact an individual by telephone regarding the furnishing of a covered item to the individual unless: the individual has given written permission to the supplier to make contact by telephone regarding the furnishing of a covered item; or, the supplier has furnished a covered item to the individual and the supplier is contacting the individual only regarding the furnishing of such covered item. We looked at the file and Medicare rules. The Plan has attested that this enrollee was contacted via an unsolicited phone call regarding provision of the item at issue. As such, no payment may be made for this item. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve an orthosis (L0650) provided August 18, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.

You asked the Plan to waive the copayment for the ambulance services. You say that you broke your right femur on August 27, 2020. You were told you were non-ambulatory and they called for an ambulance for transport to the rehab. They are charging you $250 for each trip and you do not understand. The Plan denied your request. The Plan says you were charged this cost sharing 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 $250 copayment for each ambulance trip. You had 2 ambulance trip(s). The Plan charged you $500 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on July 30, 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 a corrected claim is needed from the provider.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The file shows that the provider did not bill an appropriate CPT code for the services. The Plan is waiting on an itemized bill and corrected claim from the provider. Once this information is received, the Plan will reprocess this claim. Therefore, we decided that the Plan does not have to pay for the services rendered on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services provided on January 12, 2021.
You asked the Plan to waive the copayment for the ophthalmological services. You say that the Plan has paid this service every year and you have never had to pay a copayment. The Plan denied your request. The Plan says the claim processed with the correct copayment applied to the claim.
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 $45 copayment for Vision Care, Medicare Covered Vision Services. You have been asked to pay a $45 copayment for the ophthalmological services. The ophthalmological services falls within the Vision Care, Medicare Covered Vision Services 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 ophthalmological services provided on January 12, 2021.