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

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 14, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for each advanced radiology service. You have been asked to pay the allowed mount of $134.98, which is less than the $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99153) provided to the enrollee on January 9, 2020.
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 CPT code 99153 has a PC/TC indicator of three (3), for a technical component only code.
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 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service." 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 CPT 99153 was performed in an outpatient hospital facility on January 9, 2020. This code has a PC/TC indicator of (3) for a technical component only code and per Medicare rules, is not eligible for reimbursement when performed in an outpatient hospital setting. 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 moderate sedation services (CPT 99153) provided to the enrollee on January 9, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found that you have a history of prostate cancer with prior experimental treatment. A PET scan for subsequent treatment strategy for this diagnosis is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 2,
2020.
You asked the Plan to waive the copayment for the office visit. You say that the copayment is a lot to pay each
time. 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 a $40
copayment per Medicare-covered outpatient mental health visit.
You have been asked to pay a $40 copayment for the office visit. The office visit falls within the "Outpatient
mental health care " 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 office visit
provided on January 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac sodium 1% gel for the enrollee.You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.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 Diclofenac sodium 1% gel for the enrollee.Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin based composite, 2 surfaces, for an anterior tooth (D2331) and the resin based composite, 3 surfaces, for an posterior tooth (D2393) that you received on November 6, 2019 and November 12, 2019 by the out of network dentist.
You asked the Plan to pay for the dental services. You say that you went to another dentist and thought the price was expensive. You also say that the dentist said that she was going to make the prices better. The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan also says the provider in this case is not a network provider.
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, services received out of network are not covered. Therefore, we decided that the Plan does not have to pay for the resin based composite, 2 surfaces, for an anterior tooth (D2331) and the resin based composite, 3 surfaces, for an posterior tooth (D2393) that you received on November 6, 2019 and November 12, 2019 by the out of network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 26, 2019 through December 2, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are requesting for a reduction from $1375 to a $150 copayment. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file shows that you were admitted on November 26, 2019 and discharged on December 2, 2019. You were asked to pay a $275 copayment per day from November 26, 2019 through November 30, 2019, days 1-5 of your inpatient stay. There were no copayment charges from December 1, 2019, day 6 of your inpatient hospital care until your day of discharge December 2, 2019. Per your contract there is a $275 copayment per day required for days 1-5. 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 inpatient hospital care from November 26, 2019 through December 2, 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 should be treated at the acute level for his condition. The Plan denied your request. The Plan says the enrollee does not require inpatient hospital care for his condition.
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 enrollee has a history of ankle fracture from 2019 and has been receiving physical therapy in the home health setting. He is currently non-ambulatory due to a blister on his left leg. He was referred for inpatient rehab admission. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The patient is generally medically stable with no recent medical problems or admission to a hospital with no recent neurological events and there is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehab nursing care. He is homebound requiring max assist for bed mobility and transfers and non- ambulatory. While The patient may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you are appealing the Plan's denial because you do not feel like you should have to paythe full bill. You say that you believe you should only have to pay the copay listed in your Plan benefits.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 July 20, 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 forthe ambulance services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency department visit coded 99284 provided on October 20, 2019.You asked the Plan to pay forthe emergency department visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.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, we have confirmed that code 99284 for the emergency department visit has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency department visit coded 99284 provided on October 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not havetopre-approveMotegrity 2mg tablets.You asked the Planto pre-approvethe Motegrity tablets. You say that this medication is necessary due to the enrollee's colon surgery.The Plandenied your request. The Plansaysthis oral drug can only be covered by Part D.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 Plandoes not haveto pre-approveMotegrity 2mg tablets.Benefits for the Motegrity tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation feature, and attendant control for the power wheelchair.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the requested services are not covered.
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications. We looked at the file and Medicare rules. A power seat elevation system is not covered because it is not primarily medical in nature. Because an enrollee-operate drive control system has already been approved by the plan, an attendant control is not covered. Based on this information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat elevation feature, and attendant control for the power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), the periapical x-rays (D0220), and the periodontal maintenance (D4910) provided on September 26, 2019.
You asked the Plan to pay for the dental services. You say that the provider confirmed your eligibility and followed the proper procedure. You say that the documentation that you have states "Dental PPO", not HMO. The Plan denied your request. The Plan says dental services that you receive out of network are not covered. The Plan also says that the provider in this case is not a network provider.
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, dental services that you receive out of network are not covered. The Evidence of Coverage clearly states this. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), the bitewing x-rays (D0274), the periapical x-rays (D0220), and the periodontal maintenance (D4910) provided on September 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay formassage therapy (97124) provided on November 20, 2019.You asked the Plan to pay formassage therapy. You say that this was medically necessary.The Plan denied your request. The Plan says this is not covered under Medicare rules.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pay formassage therapy (97124) provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on February 13, 2020.You asked the Plan to waive the copayment for laboratory tests. You say that you disagree with the charges because they were always covered in the past.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory tests. Laboratory tests fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for laboratory tests provided on February 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.You asked the Plan to pre-approve a total electric hospital bed. You say that you need a total electric hospital bed to transfer in and out of bed minimizing the risk of falls.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
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 on the date of service you were
unresponsive and thrashing around. After giving you a tube of glucose, your wife called 911 and they
dispatched an ambulance and a police officer. The responders gave you additional glucose and tested your
blood sugar after restraining you. You say that you started to eventually come to and you were able to respond
to questions. Your wife was asked if you wanted to go to the emergency room by ambulance but since you
were behaving normally at that point, she declined transportation. You say that your wife called your treating
nurse the next day and she explained that the incident was a result of a diabetic seizure. You asked the Plan to
consider paying the ambulance bill. 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 October 20, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you believe that IRF care should be approved.The Plan denied your request. The Plan says the criteria for this level of care are not met.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 enrollee was admitted to the hospital on 5/20/2020 with weakness and altered mental status. He was diagnosed with sepsis. He required surgical infection treatments on the ankle and wrist on 5/29 and is non-weight bearing on the left arm and leg. Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The patient is generally medically stable with sepsis from arthritis and on antibiotics. There is no evidence of complex medical issues that require monitoring by an inpatient PMR physician three times per week or need for acute rehab nursing care. He has no endurance and is very dependent for mobility and ADLs. While The patient may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided from September 30, 2019 to January 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy 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 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 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 the psychotherapy services provided from September 30, 2019 to January 17, 2020 by an out of network (OON) provider.