Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe 8 additional therapy visits.You asked the Plan to pre-approve8 of the additional therapy visits. You say that the enrollee continues to make progress with therapy. You also say that the enrollee's shoulder pains increased while not attending therapy during her illness.The Plan denied your request. The Plan says these visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 8 additional therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.Our physician reviewer found the documentation does not reveal that prior therapy has resulted in significant objective functional improvement. Our reviewer found that the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. Our physician reviewer found that the enrollee should be able to transition to an independent home exercise program.Our reviewer also found that the requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 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 8 additional therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approvethe 8 additional therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2019 to September 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency. Additionally, coverage extends only to treatment by means of manual manipulation of the spine to correct a subluxation.
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 has network providers available who can provide 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. Additionally, the only chiropractic service Medicare covers is manual manipulation of the spine to correct subluxation of the spine. Therefore, we decided that the Plan does not have to pay for the medical services provided on August 28, 2019 to September 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 11, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical. You say that you weren't informed about a copayment. The Plan denied your request. The Plan says the copayment 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 $10 for each covered visit or consultation in an outpatient location with your PCP or other primary care physician. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you were treated for high blood pressure during the office 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 office visit provided on September 11, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services (HCPCS S9343) provided to the enrollee from August 11, 2019 to August 20, 2019.
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 this is not valid for Medicare purposes.
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 definition of HCPCS code S9343 is "Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem." We find that CPT code S9343 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home health services (HCPCS S9343) provided to the enrollee from August 11, 2019 to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on October 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the vision care. You say that you assumed that seeing the provider in the facility would be the same as every other doctor you have seen and had coverage for. You say that had you known it would not be covered you would not have seen them. You also say that you were unaware that the provider was not associated with your plan. The Plan denied your request. The Plan says authorization was not obtained before you received the service. The Plan also says the service was not 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 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 exam provided on October 15, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe lab services you received on September 3, 2019.You asked the Plan to waive the copay forthe lab services. You say that the copays add up, and you want this one waived.The Plan denied your request. The Plan says the copay applies per your benefits coverage.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copay for Medicare-covered lab tests. You have been asked to pay a $5 copay for Medicare-covered lab tests for the lab services. The lab services falls within the outpatient diagnostic 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 copay forthe lab services you received on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 25, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say you should not be responsible for the copayment. 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 $40 copayment for each Medicare-covered office visit to other providers for urgently needed services. You have been asked to pay a $40 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 urgent care visit provided on September 25, 2019.
Your complaint that the stitches did not take and you had to return the next day 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.
You asked the Plan to pre-approve the inpatient mental health services. You say that the records provided support the need for inpatient mental health services. The Plan denied your request. The Plan says the requested inpatient psychiatric services are not medically necessary because the records received show that the enrollee's condition has improved and she is no longer a threat to herself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the inpatient mental health services. Our reviewer says that the criteria for coverage of inpatient mental health services have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on February 15, 2020 with Major Depressive Disorder. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question, as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question, as she did not have dangerousness to self or others but was compliant with her treatment. This enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question.
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 inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the cataract surgery you received on September 24, 2018.
You asked the Plan to waive the copay for the surgery services. You say that you would not have gotten the surgery if there was an expense. The Plan denied your request. The Plan says the copay was applied based on your plan benefits.
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 copay per day for outpatient surgery. You have been asked to pay a $350 copay for the surgery services. The services 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 waive the copay for the cataract surgery you received on September 24, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (E1390) provided on April 19, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says per a phone call to the provider's office on January 3, 2020, the balance on your account is currently $9.93. The Plan states this amount is less than the benefit for DME.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received an oxygen concentrator (E1390) provided on April 19, 2019. You have been asked to pay 20% coinsurance of the allowed amount for the DME. The allowed amount is $85.03. The total you would owe is $17.01 ($85.03 x 20% = $17.01). However, per a phone call to the provider's office on January 3, 2020, the balance on your account is currently $9.93. The Plan states this amount is less than the benefit for DME. 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 oxygen concentrator (E1390) provided on April 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on September 18, 2019.
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 Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory
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 has network providers available who can provide 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 chiropractic services provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two osseous surgery procedures.
You asked the Plan to pre-approve the osseous surgery procedures. You say that you recently had teeth removed on one side of your jaw and your dentist is trying to save the teeth in the back on the other side. You also say that you have an infection under your teeth and this procedure will remove the infection and hopefully stop the bone decay. The Plan denied your request. The Plan says this service is not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two osseous surgery procedures.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the urgent care visit provided on October 7, 2019.
You asked the Plan to reduce the copayment for the urgent care visit. You say that you usually pay a $10 copayment when you see a doctor. You say nothing was urgent about the visit. 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 $45 copayment for each Medicare-covered office visit to other providers for urgently needed services. You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were seen at an urgent care center.
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 urgent care visit provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on October 17, 2019.You asked the Plan to pay forthe office visit. You say that on this visit, the doctor showed you and explained an MRI but did not do an actual manipulation. The Plan denied your request. The Plan says Medicare only covers manual manipulation of the spine to correct a subluxation.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 an office visit (99213) provided on October 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 17000) provided to the enrollee on August 26, 2019.
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 since the original procedure or service has not been identified, the line appended with modifier 79 has been denied.
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 17000 is "Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses)." 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 services at issue in this case were not coded correctly. Our coding reviewer found the medical records provided do not include information to validate what the original procedure or service was that was performed on the enrollee related to the post-operative period requiring the use of a 79 modifier. Since the original procedure or service cannot be identified, the use of a 79 modifier is inappropriate. 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 surgical services (CPT 17000) provided to the enrollee on August 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided from January 17, 2016 to December 17, 2016.
You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the claim was filed after the time limit.
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 the claim was filed beyond the time limit. Therefore, we decided that the Plan does not have to reimburse you for a gym membership provided from January 17, 2016 to December 17, 2016.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) provided on October 1, 2019.
You asked the Plan to pay for needle electromyography. You say that this code should be paid. The Plan denied your request. The Plan says this code is not supported by the records.
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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 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 needle electromyography. Our reviewer says that the use of CPT 95886 is not supported in the record. Our physician reviewer found the medical records provided do not include documentation of 2 units of Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels. Therefore, the service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) provided on October 1, 2019.