Persius/hicric huggingface dataset:
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 you require additional time in the hospital and admission to an LTACH is necessary. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available and covered at the acute care hospital where you are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a repeat CT scan of the chest.
You asked the Plan to pre-approve the scan. You say that this is medically necessary to see if treatment needs to continue. The Plan denied your request. The Plan says that the request is overlapping imaging, as the initial staging has been completed.
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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found this is needed to have a current idea of measurements of the metastatic lesions to compare with after a couple months of treatment. The documentation supports that the requested CT scan of the chest was medically reasonable and necessary for this enrollee with metastatic urothelial cancer. 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 scan have been met. Therefore, we decided that the Plan has to pre-approve a repeat CT scan of the chest.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for annual wellness visit (G0438) provided on March 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the annual wellness visit. You say that you had called to change the PCP for the remaining time left on your policy and the change was not made. You feel if the change had been made then the claim wound not have denied for no referral on file. 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 annual wellness visit (G0438) provided on March 3, 2021 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 physician services provided on February 27, 2021 to February 28, 2021 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 physician services provided on February 27, 2021 to February 28, 2021 by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a skin rash. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (unattended), to one or more areas for
indication(s) other than wound care, as part of a therapy plan of care (G0283) provided February 9, 2021 to
February 18, 2021.

You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial of payment
of your four chiropractor visits. The Plan denied your request. The Plan says this service is not covered under
the Plan benefits.

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. Therefore, we decided that
the Plan does not have to pay for electrical stimulation (unattended), to one or more areas for indication(s)
other than wound care, as part of a therapy plan of care (G0283) provided February 9, 2021 to February 18,
2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the test for the detection of respiratory disease-causing organisms (0223U) provided on December 31, 2020.
You asked the Plan to pay for the test for the detection of respiratory disease-causing organisms. You say that you would like reconsideration because this code is covered by Medicare. The Plan denied your request. The Plan says this is not a Medicare-covered service.
The Plan must follow Medicare rules. Medicare rules say that tests that include more than 5 viral pathogens are non-covered.
We find that CPT code 0223U is not supported in the record. Specifically, CPT code 0223U is listed as a Group 2 Code and is therefore non-covered. Based on this information, we decided that Medicare rules for coverage of the test for the detection of respiratory disease-causing organisms have not been met. Therefore, we decided that the Plan does not have to pay for the test for the detection of respiratory disease-causing organisms (0223U) provided on December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99326) provided on February 23, 2021 to March 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the nursing home is responsible to obtain prior authorization for their patients, which should cover medical treatments by the provider. 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 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 domiciliary or rest home visit (99326) provided on February 23, 2021 to March 23, 2021 by an out-of-network (OON) provider.services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-plan nephrologist.
You asked the Plan to pre-approve these services. You say that you want to be referred out of plan. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to a non-plan nephrologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on March 3, 2021.

You asked the Plan to waive the copayment for laboratory tests. You say that your inpatient surgery got canceled, therefore, the laboratory tests were not necessary and you feel that you should not be responsible for the charges. 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 $10 copayment for laboratory tests. 

You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests 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 for laboratory tests provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a sphere lens (V2100) provided on May 22, 2020.
You asked the Plan to pay for a sphere lens. You say that you receive one eye exam every two years and would like reimbursement for this visit. The Plan denied your request. The Plan says you have exhausted your benefit.
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 contract says that you have a $100 allowance once per year to use towards the purchase and fitting of eyeglasses and pair of lenses or contact lenses. We looked at the file and the Plan's rules. The records show you exhausted your $100 maximum allowed benefit on July 3, 2020 because the claim was submitted before the May 22, 2020 claim. The records also show that you are not being billed for an eye exam. Based on this information, we decided that the Plan's rules for coverage of a sphere lens have not been met. Therefore, we decided that the Plan does not have to pay for a sphere lens (V2100) provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on March 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 rest home visit provided on March 3, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered on February 2, 2021 to
February 25, 2021.
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 claims were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that a valid HIPPS code is required for home health
claims.
We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid HIPPS
code. 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 home health services rendered on
February 2, 2021 to February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120), the prophylaxis (D1110), and the 
unspecified preventive service (D1999) provided on March 13, 2021. 
 
You asked the Plan to pay for the dental services. You say that you called and asked about out of network 
dental. You say that you were told you could file out of network claim which ended up being a routine 
cleaning. You say that you feel that you should be reimbursed for something because you have dental coverage. 
The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that 
dental services performed out of network are not covered. The Plan also says that there is no record that you 
contacted the plan to verify the provider's network status prior to the date of 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided December 18, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance service was related to a previous COVID-19 infection and therefore you should not have to pay a copayment. The Plan denied your request. The Plan says this claim had no COVID-19 related billing to consider waiving of copayments. The copayment was applied correctly to the ambulance service.
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 $265 copayment for ground ambulance services per date of service.
You have been asked to pay a $265 copayment for the ambulance services. This service falls within the Ambulance 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided December 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard (D9944), the occlusal guard adjustment
(D9943), and the unspecified preventive service (D1999) provided on April 7, 2021.

You asked the Plan to pay for the dental services. You say that you are hoping that some of the cost is covered
under your medical insurance. You The Plan denied your request. The Plan says occlusal guard, occlusal guard
adjustment, and the unspecified preventive service are not listed as covered service. The Plan says that the
claim processed correctly. The Plan also says that the dental claim has been sent to the medical claims team for
processing under your medical plan and you will receive claim processing details when complete.

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 dental services you received are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
occlusal guard (D9944), the occlusal guard adjustment (D9943), and the unspecified preventive service
(D1999) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Botox injection provided on April 21, 2021.

You asked the Plan to waive the coinsurance for a Botox injection. You say that the injections are necessary to treat your condition and you were not charged in the past. 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 20% coinsurance for Medicare part B prescription drugs. 

You received a Botox injection on April 21, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $3,058.77 and 20% of that is $611.75.

You have been asked to pay the total coinsurance amount of $611.75 for a Botox injection. A Botox injection falls within the Medicare part B prescription drugs 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 a Botox injection provided on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a gene panel (81404, 81406, 81407, 81408) provided on December 9, 2020.
You asked the Plan to pay for a gene panel. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. If a laboratory assays 2 or more genes in a patient in parallel, then those 2 or more genes will be considered part of the same panel. A panel constitutes a
single procedural service, so 1 code must be submitted for the panel. We find that CPT codes 81404, 81406, 81407, and 81408 are not supported in the medical record. Specifically, the genetic testing at issue was performed as a panel and should be reported with a single code. Based on this information, we decided that Medicare rules for coverage of a gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a gene panel (81404, 81406, 81407, 81408) provided on December 9, 2020.