Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (CPT 90834) provided to the enrollee on April 6, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a diagnosis of F17.210 (nicotine dependence, cigarettes, uncomplicated) is not considered appropriate for psychotherapy
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 90834 is "Psychotherapy, 45 minutes with patient." The ICD-10 definition of diagnosis code F17.210 is "nicotine dependence, cigarettes, uncomplicated)." We find that CPT code 90834 is not supported in the medical record. Specifically, Medicare does not consider F17.210 to be an appropriate diagnosis code to use with psychotherapy coded with CPT 90834. Additionally, despite it being requested, you did not provide any medical records for use in this case. 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 psychotherapy services (CPT 90834) provided to the enrollee on April 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the copayments for cataract surgeries provided on
March 23, 2021, and April 13, 2021.
You asked the Plan to reimburse you the copayments for the cataract surgeries. You say that the copayment
amounts are too high. The Plan denied your request. The Plan says you were charged the copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for Outpatient surgery.
You have been asked to pay a $350 copayment for the cataract surgeries. The cataract surgeries fall within the
Outpatient surgery 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 reimburse you the copayments for cataract
surgeries provided on March 23, 2021, and April 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transportation (A0428, A0425) provided on October 23, 2020.
You asked the Plan to waive the copayment for non-emergency ambulance transportation. You say that you did not request the transport and were not given the opportunity to request an in-network provider. 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 $275 copayment for ambulance services. You have been asked to pay a $275 copayment for non-emergency ambulance transportation. The services at issue fall 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 non-emergency ambulance transportation (A0428, A0425) provided on October 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99213, 97012, G0283) provided January 14, 2021 to March 18, 2021.

You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 chiropractic services (99213, 97012, G0283) provided January 14, 2021 to March 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the chemotherapy administration, drugs and 
injection provided on May 18, 2020. 
 
You asked the Plan to waive the cost for the chemotherapy administration, drugs and injection. You say that 
the incorrect policy was activated and all your out-of-pocket costs in 2020 were in-network. You say that the 
out-of-pocket was reached before June 15, 2020 and a refund is due. The Plan denied your request. The Plan 
says the cost share applied correctly to the services provided on May 18, 2020 and the remaining charges were 
waived because you met your maximum-out-of-pocket. 
 
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 $50 
copayment for in-network, Medicare-covered physician specialist services and 20% coinsurance for 
chemotherapy drugs from a network provider.  
 
You have been asked to pay a total of $4,369.65, which is less than the standard 20% coinsurance because you 
met your maximum out-of-pocket. The chemotherapy administration falls within the "Physician/Practitioner services, including doctor's office 
visits" benefit category. The chemotherapy injection and drugs fall 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 cost for the chemotherapy administration, drugs 
and injection provided on May 18, 2020.  
 
Your complaint about being taken advantage of is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the SNF admission is not medically necessary. Her needs can be safely addressed in lower intensity, alternate level such as home or in a long-term care facility with 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 20, 2020.

You asked the Plan to pay for a limited oral evaluation. You say that the provider billed your medical Plan, not the dental Plan. You were told to appeal the denial. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospitalization.
You asked the Plan to pre-approve acute inpatient hospitalization. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospitalization. Our reviewer says that inpatient hospitalization is not medically necessary in this case. Our physician reviewer found you were approved for an elective non-emergent left hip arthroplasty. You have no significant past medical history or other acute condition that would warrant inpatient services.
The documentation does not suggest you will require hospital services that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospitalization have not been met. Specifically, medically necessary services can be provided in an observation level of care. This means admission into an inpatient hospital is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospitalization.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility visits provided from December 6, 2020, to December 15, 2020.
You asked the Plan to pay for skilled nursing facility visits. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for these services is correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide any rationale or evidence to support a denial of payment for these services. The Plan approved coverage for date of service December 4, 2020 but denied coverage for the remaining dates of service billed on this claim. Without any denial rationale or supporting evidence, the Plan has not shown that their decision to deny payment for these services is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for skilled nursing facility visits provided from December 6, 2020, to December 15, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic mammogram and ultrasound provided on March 31, 2021.

You asked the Plan to waive the deductible for the diagnostic mammogram and the ultrasound. You say that you should not have to pay for the services because you did not have to pay for your mammogram in 2013. 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. Your contract with the Plan says that there is a $750 copayment that applies towards basic imaging service such as general x-rays and ultrasounds. 

The diagnostic mammogram and the ultrasound you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 copayment that applies to the diagnostic mammogram and ultrasounds. The record shows you had a diagnostic mammogram due to a suspicious lesion that was found on the screening mammogram on March 16, 2021.

This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammogram and the ultrasound were received on March 31, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic mammogram and ultrasound provided on March 31, 2021.

Please note, our decision is only regarding the March 31, 2021 date of service. Please contact the Plan directly for any questions regarding previous years' billing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 17, 2020 by an out-of-network provider.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider the charges. The Plan denied your request. The Plan says you did not request 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 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 laboratory services provided on December 17, 2020 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid stance extension dampening feature (L5848) and endoskeletal knee-shin system microprocessor control feature (L5856).

You asked the Plan to pre-approve fluid stance extension dampening feature and endoskeletal knee-shin system microprocessor control feature. You say that these items are medically necessary. The Plan denied your request. The Plan says these requested items cannot be used with the requested prosthesis.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 fluid stance extension dampening feature and endoskeletal knee-shin system microprocessor control feature. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 61 year old female with a past medical history of a non-healing tibia fracture who has undergone a right above-the-knee amputation and who requires a lower extremity prosthesis. Based on the limited medical records provided, there is no documentation that the requested accessories for the prosthesis (L5848, L5856) are medically reasonable and necessary and can be used with the requested 3R80 knee that has been approved by the Plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of fluid stance extension dampening feature and endoskeletal knee-shin system microprocessor control feature have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid stance extension dampening feature (L5848) and endoskeletal knee-shin system microprocessor control feature (L5856).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any skilled nursing needs or skilled therapy needs daily in an inpatient setting.

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 admission have not been met. Specifically, you require a level of care that can not be provided in a SNF setting. This means admission to a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen 10% vial.
You asked the Plan to pre-approve Privigen. You say that this drug is medically necessary. The Plan denied your request. The Plan says the use of the requested drug is considered experimental/investigational for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Privigen. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the record indicates that the enrollee has a history of IgM mediated peripheral neuropathy sensory greater than motor. In this case, this diagnosis is not coverable under Part B. Furthermore, the Medicare approved drug compendia do not contain a positive citation for the use of the requested drug in this clinical scenario. The elements of the coverage rule are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen 10% vial.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye surgery provided on February 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the eye surgery. 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 eye surgery provided on February 8, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no skilled nursing needs and at the current level of function, the enrollee does not require daily skilled therapy services on an inpatient basis. The enrollee's advanced age, Alzheimer's disease and inability to take part in therapies are a barrier for any rehabilitation program and will not benefit from therapies. 

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 SNF care have not been met. Specifically, this enrollee will not benefit from SNF care. This means the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020, by 
an OON provider. 
 
You asked the Plan to pay for the laboratory services. 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 payable. 
 
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 laboratory services provided on November 30, 
2020, by an OON provider.