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

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 2, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment because you went to the emergency room because you were referred there. The Plan denied your request. The Plan says you have been charged 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 $100 copayment for emergency care. You have been asked to pay a $100 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows you received services during your emergency room visit.
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 emergency room visit provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the endovenous ablation therapy (36478). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is not a benefit for out-of-network coverage unless the services are urgent, and emergency or cannot be provided in-network.
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 the medical services to be provided by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on August 9, 2019.You asked the Plan to waive the copay forthe ambulance transport. You say that you should not be liable.The Plan denied your request. The Plan says that cost-sharing 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 saysthat you must pay a $250 copay for ground ambulance services. You have been asked to pay a $250 copay for the ambulance transport. The ambulance transport falls within the ground 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 copay forthe ambulance transport provided on August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for various lab services (CPT 81240, 81241, 81291, 82523, 82985, 82310, 83036, 83876, 83880, 84134, 85385) provided to the enrollee on January 17, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CPT 81291 is not a covered benefit. The rules also say that lab tests are covered when they are medically accepted in the literature, and medically necessary to establish a diagnosis and guide medical management.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found in this case, Iron studies may be appropriate in patients after treatment for other nutritional deficiency anemias.Due to Vitamin B and D deficiencies under treatment, testing may be medically necessary to ensure adequate replacement has been accomplished. The review has determined that the lab services provided to the enrollee were 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 services have not been met.Therefore, we decided that the Plan does not have to pay forvarious lab services (CPT 81240, 81241, 81291, 82523, 82985, 82310, 83036, 83876, 83880, 84134, 85385) provided to the enrollee on January 17, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plan says three hours of therapy per day are not needed, and an intensive team approach is not needed.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 fileand 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. Ourphysician reviewer found the enrollee was medically stable with no evidence of need for supervision by PMR Physician or needs acute rehab nursing care. She may benefit from further PT and OT but does not require an intensive therapy program. IRF admissionis not medically necessary based on her current functional status and medical stability.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were at the local senior center when
you began to feel ill and very weak. The office called 911 and when the EMTs arrived they checked your
vitals. They thought you should go to the hospital, and since you were feeling better you had your wife take
you. You stated that you thought you were doing the responders a favor by transporting yourself since they are
busy. You believe the Plan should cover the cost of the 911 call since you were eventually admitted to the
hospital. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 23, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that this is necessary to control the enrollee's blood sugar. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Trulicity.
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the knee injection provided on April 16, 2019.
You asked the Plan to reduce the copayment for the knee injection. You say that the copayment for outpatient services is too expensive and you cannot afford it. The Plan denied your request. The Plan says you have been charged 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 $250 copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the knee injection. The knee injection 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 reduce the copayment for the knee injection provided on April 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical vagus nerve stimulation.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your
request. The Plan says electro-acupuncture is not a covered service, as it is a new agent of unknown use and
efficacy in the United States.
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, this is not standard acupuncture treatment for low
back pain. Therefore, we decided that the Plan does not have to pay for electrical vagus nerve stimulation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for catheter insertion surgery (92928, G0500, 93458) and an office visit (99214) provided from September 9, 2019 to September 10, 2019.
You asked the Plan to waive the coinsurance for catheter insertion surgery (92928,G0500, 93458) and an office visit. You say that your cost share should be lowered to the 2020 contract amount. The Plan denied your request. The Plan says these services processed 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 outpatient hospital services and a $40 copayment for specialist visits. You have been asked to pay $40 for an office visit with a specialist and $3,854.43 ($19,272.14 allowed amount x 20% coinsurance =$3,854.43) 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 catheter insertion surgery (92928, G0500, 93458) and an office visit (99214) provided from September 9, 2019 to September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a right knee orthosis (L1851-RT), a right suspension sleeve (L2397-RT), a left knee orthosis (L1851-LT), and a left suspension sleeve (L2397-LT) provided to the enrollee on January 18, 2019.
You asked the Plan to pay for the orthoses and sleeves. You say that the claim should be paid. The Plan denied your request. The Plan says the encounter appears to be a Telehealth service encounter however Telehealth guidelines have not been 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 pay for the orthoses and sleeves. Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee's chief complaint was bilateral knee pain. The documentation in the case file does not support that the requested bilateral knee orthoses and sleeves were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. An appropriate physical examination of the knees would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the bilateral knee orthoses and sleeves were medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the knees. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeves have not been met. Therefore, we decided that the Plan does not have to pay for a right knee orthosis (L1851-RT), a right suspension sleeve (L2397-RT), a left knee orthosis (L1851-LT), and a left suspension sleeve (L2397-LT) provided to the enrollee on January 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left custom molded ankle-foot orthosis (L1940-LT), a right custom molded ankle-foot orthosis (L1971-RT), and additional items (L2330) (L2820).
You asked the Plan to pre-approve the orthoses and additional items. You say that the enrollee needs these braces. The Plan denied your request. The Plan says the submitted documentation did not support the need for a custom-fabricated orthosis rather than a prefabricated orthosis.
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 orthoses and additional items. Our reviewer says that the items are not medically necessary. Our physician reviewer found the enrollee is noted to have bilateral ankle and foot pain. There is no evidence of joint laxity or instability, or that the enrollee was unable to be fitted with a prefabricated AFO. There is no evidence that the enrollee's joint movements need to be restricted in more than one plane, and no evidence that the enrollee needs a custom fitted AFO to prevent tissue injury. There is no evidence of a fracture requiring treatment with a custom fitted AFO. As such, the requested custom fitted AFOs are not shown to be currently medically necessary or reasonable. 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 orthoses and addition items have not been met. Therefore, we decided that the Plan does not have to pre-approve a left custom molded ankle-foot orthosis (L1940-LT), a right custom molded ankle-foot orthosis (L1971-RT), and additional items (L2330) (L2820).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto payfordrug testing services provided to the enrollee on March 26, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysealthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.We find that HCPCS code G0481 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on March 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services rendered to the enrollee on December 13, 2018.
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 code was billed with the invalid -25 modifier.
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 88305 is Level IV surgical pathology. We find that CPT code 88305 is not supported in the medical record. Specifically, the code was billed with the -25 modifier. This modifier is for physician evaluation and management services and is not appropriate when billed with a pathology 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 pathology services rendered to the enrollee on December 13, 2018.
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 enrollee requires the care of physicians, nurses, wound care, and rehab.The Plan denied your request. The Plan says the low complexity of the enrollee's medical and rehab needs do not require a coordinated team approach to care.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 physician reviewer found that the enrollee's current level of function is supervised to moderate assist for ambulation and activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require anacute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that his medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level 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 inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a donation on January 1, 2019.
You asked the Plan to reimburse you for the donation. The Plan denied your request. The Plan says a donation is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because a donation is not a Plan covered benefit. Therefore, we decided that the Plan does not have to reimburse you for a donation on January 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on May 2, 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 there is no valid physician order. The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on May 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 3, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered to the enrollee on June 3,
2019.
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 the enrollee can tolerate multiple therapies and would benefit from therapy. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional therapies of physical therapy and occupational therapy, but the enrollee does not require these on an intensive rehabilitation therapy program level 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 inpatient rehabilitation facility (IRF) admission and services.