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

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on July 13, 2020, to July 19, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care/preferred provider.

You have been asked to pay a $275 copayment per day for days 1-6. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,650 ($275 x 6 days = $1,650). The correct copayment has been applied to the services that were provided. An inpatient hospital stay falls within the inpatient hospital care/preferred provider benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on July 13, 2020, to July 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 14001) provided on February 10, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 14001 is "Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm." 

We asked our coding 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 use of CPT code 14001 is not supported by the records provided. Our coding reviewer found that the operative report supports a direct closure or repair, which is not an adjacent tissue transfer or rearrangement. Therefore, CPT 14001 cannot be confirmed as performed. 

We looked at this coder'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 for the services (CPT 14001) provided on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 4, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for the unspecified preventive service (D1999) provided on December 1, 2020.

You asked the Plan to pay the in network rate for the unspecified preventive service. You say that you found this provider on the Plan's website to be listed as in network. The Plan denied your request. The Plan says the unspecified preventive service is not listed as covered. The Plan also says that you did not call to verify your benefits and provider eligibility 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. 

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 the in network rate for the unspecified preventive service (D1999) provided on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on December 16, 2020.

You asked the Plan to waive the copayment for these services. You say that you didn't have a copayment before. The Plan denied your request. The Plan says the copayment 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 copayment per visit for laboratory tests.

Review of the file shows that you received laboratory services on December 16, 2020. You have been asked to pay a $20 copayment for these services. These services fall within the laboratory tests 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 laboratory services rendered on December 16, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services rendered on May 25, 2019 to May 27, 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 the claim was not filed timely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until December 28, 2020. A valid Waiver of Liability (WOL) was not received until February 12, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency room services rendered on May 25, 2019 to May 27, 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 you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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. Our
physician reviewer found the enrollee was admitted for expressive aphasia and was treated for a stroke. The
enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not
support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be
met at a lower level of 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (K0800) and accessory (K0108).

You asked the Plan to pre-approve a power operated vehicle. You say that you would like the Plan to reconsider coverage. The Plan denied your request. The Plan says this device is intended for use outside of the home which is not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800) and accessory (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on December 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 drug testing provided on December 8, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on October 22, 2020.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the diagnostic radiology services. 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 diagnostic radiology services provided on
October 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673) provided on
September 14, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The
Plan denied your request. The Plan says this is not covered.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism is a preventive service. The rules also say that PCD related
accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672,
E0673) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652,
E0675) meets the applicable coverage criteria for that type of PCD.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record shows that the PCD at issue was prescribed for
the purpose of prevention of venous thromboembolism. The item at issue was also billed as an accessory
without an appropriate related base PCD. Therefore, we decided that the Plan does not have to pay for a
pneumatic compression device (E0673) provided on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intermittent limb compression device.

You asked the Plan to pre-approve the intermittent limb compression device. You say that the intermittent limb compression device should be covered. The Plan partially denied your request. The Plan says this enrollee's condition would benefit from a basic lymphedema pump. This item is available through a contracted durable medical equipment provider. It would be covered from Tactile, but not the requested Medical Supply Cabinet, Inc.

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 an intermittent limb compression device.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the MRI of the face and neck (70543).

You asked the Plan to pre-approve the MRI. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says that this service is not medically necessary.

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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the last imaging was in October 2020. The requested service comes at a six-month interval and is consistent with the record indicating the request in three months from the office visit. 

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 MRI have been met. Therefore, we decided that the Plan has to pre-approve the MRI of the face and neck (70543).

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 pre-approve repeat medial branch block (MBB) injections.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that repeat MBBs are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and pancreatic cancer. She had a prior spinal fusion and diagnostic MBBs on January 14, 2021. The prior injections provided 50 percent pain relief. The criteria for coverage of repeat MBBs are therefore not met and the services are not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat medial branch block (MBB) injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.

You asked the Plan to pre-approve a PET scan. 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 medically necessary.

The Plan follows Medicare rules. Medicare rules say that PET scans are only covered for certain indications. 

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 PET scan. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have a history of a memory impairment. A neuropsychology evaluation led to a diagnosis of mild cognitive impairment (MCI). The member in this case does not meet diagnostic criteria for either Alzheimer's disease (AD) or fronto-temporal dementia (FTD) at this time. Therefore, the enrollee does not meet criteria for the requested services. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to reimburse you for the comprehensive oral evaluation (D0150), and the bitewing x-rays (D0274) provided on December 8, 2020.

You asked the Plan to reimburse you for the dental services. You say that you paid $140 for the dental services. You say that a plan representative advised that this dental office was in network. You also say that you should be reimbursed. The Plan denied your request. The Plan says that the provider in this case is out of network. The Plan also says that payment cannot be made for services performed by a provider that has opted out of Medicare.

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. The Plan covers the dental services when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to reimburse you for the comprehensive oral evaluation (D0150), and the bitewing x-rays (D0274) provided on December 8, 2020.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can receive the care she needs in another setting, such as home, a long-term care facility, or other outpatient setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power-operated vehicle (K0800) and accessory (K0108).

You asked the Plan to pre-approve a power-operated vehicle and accessory. You say that you would like the Plan to cover this service. The Plan denied your request. The Plan says coverage is not available for equipment intended to be used outside of the home.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power-operated vehicle (K0800) and accessory (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine and comprehensive dental services rendered by an out-of-network (OON) provider.

You asked the Plan to pre-approve routine and comprehensive dental services. You say that this dentist provides the best service at a lower cost and should be covered.The Plan denied your request. The Plan says there are network providers available to provider routine dental service and you do not meet criteria for OON coverage.

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. The Plan covers routine and comprehensive dental services when the services are medically necessary and reasonable. 

We looked at the file, and Medicare rules. 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.Based on this information, we decided that the Plan's rules for coverage of routine and comprehensive dental services have not been met.Therefore, we decided that the Plan does not have to pre-approve routine and comprehensive dental services rendered by an out-of-network (OON) provider.