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

We decided that the Plan does not have to pay for rest home services provided on October 25, 2019 by an out of network (OON) provider. You asked the Plan to pay for rest home services. You say that the facility requested their nurse practitioner to see the enrollee. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 rest home services provided on October 25, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs device.
You asked the Plan to pre-approve the CardioMEMs device. You say that this device is medically necessary because the member has heart failure exacerbation. The Plan denied your request. The Plan says the CardioMEMs device is not medically necessary.
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 the CardioMEMs device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure. 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 CardioMEMs device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7210), and the bone replacement graft (D7953) provided on September 16, 2019.You asked the Plan to pay for the extraction and bone replacement graft. You say that you are on a fixed income. You say that you cannot afford to pay this bill.The Plan denied your request. The Plan says extractions are not a covered service. The Plan also says that bone replacement grafts are not a covered service either.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 surgical extraction and bone replacement graft are not listed as covered services.Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7210), and the bone replacement graft (D7953) provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on July 18,
2019.
You asked the Plan to waive the copayment for the laboratory work. You say that the lab is a part of the
hospital building. You say you did not know that the lab was separate. 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $70 copayment for laboratory services at an in-network outpatient hospital.
The enrollee has been asked to pay a $70 copayment for the laboratory work. The laboratory work falls within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you
were billed by the outpatient hospital.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This
cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the laboratory work provided on July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued CPAP approval.You asked the Plan to pre-approve the services. You say that this should be paid for.The Plan denied your request. The Plan says the download from the machine showed that the machine was used 5 nights (17%) out of 30 for at least four hours.The Plan must follow Medicare rules. Medicare rules say that continued use of CPAP can be approved if there is objective evidence of adherence to 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you did did not show adherence to the CPAP therapy to necessitate continued use of this therapy. You demonstrated use of the CPAP for more than 4 hours per night only 17% of the time between 2/18/20 and 3/18/20. Of note, the plan has agreed to allow you to use the CPAP device for another month to work on your compliance -this extra month of coverage seems reasonable given the difficulties reported by the enrollee with adjusting to the device.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued CPAP approval.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care from October 9, 2019 through October 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay 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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that he record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two 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 hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care from October 9, 2019 through October 12, 2019.
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 reduce the copayment for the MRI provided on August 14, 2019.You asked the Plan to reduce the copayment for the MRI. You submitted the itemized bill regarding the MRI. The Plan denied your request. The Plan says you have been reimbursed an amount of $40 and 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 $200 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay a $200 copayment for the MRI. The MRI 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 reduce the copayment for the MRI provided on August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous passive motion (CPM)
device.
You asked the Plan to pre-approve continued use of a continuous passive motion (CPM) device. You say that
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are
not covered.
The Plan must follow Medicare rules. The rules say that coverage for CPM devices is limited to the three-week
period following total knee replacement surgery during which the device is used in the home.
Records show that knee replacement surgery was received on February 20, 2020. The file shows that a CPM
device was used for three weeks following this surgery. Therefore, we decided that the Plan does not have to
pre-approve continued use of a continuous passive motion (CPM) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for DME repair (K0739) provided on September 30, 2019.
You asked the Plan to pay for the DME repair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records submitted do not support the service billed.
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 K0739x14 is repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes. We asked our coder 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 DME repair. Our reviewer says that CPT code K0739x14 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include total time spend doing a Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes, therefore, the service cannot be verified. 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 DME repair have not been met. Therefore, we decided that the Plan does not have to pay for DME repair (K0739) provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 11, 2019.
You asked the Plan to pay for the physician's services. You say that when you arrived at the physician's office, you asked whether you had coverage with your policy number 932294077 and the secretary said that they did accept your plan with a copayment of $50.00. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 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 physician's services provided on October 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrocentesis (20610) and fluoroscopic guidance (77002).
You asked the Plan to pre-approve the arthrocentesis and fluoroscopic guidance. You say that you would like reconsideration as the injection is medically necessary. The Plan denied your request. The Plan says you have not benefited from long lasting pain control after this procedure in the past.
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 the arthrocentesis and fluoroscopic guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of significant or sustained pain relief with these injections, resulting in an improvement in functional capacity. 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 arthrocentesis and fluoroscopic guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrocentesis (20610) and fluoroscopic guidance (77002).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy and office visit provided on September 4, 2019 and September 13, 2019. You asked the Plan to waive the copayment for the cystoscopy and office visit. You say that you have previously had the same procedure and the follow up visit was covered in full. The Plan denied your request. The Plan says the copayments 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 for a specialty physician. Covered services include medically necessary medical care or surgery services furnished in a physician's office. You have been asked to pay a $20 copayment for the cystoscopy and a $20 copayment for the office visit. The cystoscopy and office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up. 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 cystoscopy and office visit provided on September 4, 2019 and September 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the presbyopia-correcting (P-C) IOL provided on November 7, 2019 and November 14, 2019.
You asked the Plan to pay for the P-C IOL. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the P-C IOL is not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a conventional IOL. While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting feature of a P-C IOL. Therefore, we decided that the Plan does not have to pay for the presbyopia-correcting (P-C) IOL provided on November 7, 2019 and November 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 30,
2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on
July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the podiatry services rendered to you on July 25, 2019.
You asked the Plan to waive the deductible for these services. You say that the provider's office told you that they accepted your insurance. The Plan denied your request. The Plan says the deductible was applied correctly.
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 $750 combined in- and out-of-network deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the podiatry benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 combined in- and out-of-network deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on July 25, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the podiatry services rendered to you on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordeluxe frames (V2025) progressive lenses (V2781) polycarbonate lenses (V2784) lenses, single vision (V2100) anti-reflective coating (V2750) provided by an out of network provider on June 3, 2019You asked the Plan to pay forthe vision services. You say that you were referred to this provider and you had believed the provider's assistant was giving you correct information that the services would be covered and you would like to be reimbursed.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by an in network provider. We looked at the file and the Plan's rules. services rendered by an out of network provider is not covered by the plan Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan doesnot have to pay fordeluxe frames (V2025) progressive lenses (V2781) polycarbonate lenses (V2784) lenses, single vision (V2100) anti-reflective coating (V2750) provided by an out of network provider on June 3, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee on October 29, 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 the documentation received does not match the provider.
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 70450 is "Computed tomography, head or brain." We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found there is valid clinical info and documentation to support billing for CPT 70450 but there is no valid reason for the 26 or 59 modifiers which were also billed for the same exam. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 70450) provided to the enrollee on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from November 26, 2019 to December 13, 2019. You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 chiropractic 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 chiropractic services provided from November 26, 2019 to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 17, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 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 physician's services provided on September 17, 2019.