Persius/hicric huggingface dataset:
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's current medical condition requires daily, medically necessary oversight by a physician to monitor incision and healing, to manage medication changes, treat pain, physical therapy and occupational therapy, and dietary consult. You say that the enrollee's clinical condition meets the full IRF criteria, and a lower level of care cannot provide the care needed. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the services needed can safely be received at an alternate level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99309) provided on March 26, 2021. 
 
You asked the Plan to pay for nursing facility care. You say that this should be covered. The Plan denied your 
request. The Plan says this was provided by a provider that is not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for nursing facility care (99309) provided on 
March 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram, diagnostic digital breast tomosynthesis, and breast ultrasound you had at an outpatient hospital facility on March 24, 2021.

You asked the Plan to waive the copayment for the diagnostic mammogram, tomosynthesis, and breast ultrasound. You say that these tests were needed because you are a cancer patient and you have never had a charge for these services as they are preventive. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that these were diagnostic tests, not preventive tests.

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 $100 copayment for diagnostic procedures and tests at an outpatient hospital. 

You have been asked to pay a $100 copayment for the diagnostic mammogram, tomosynthesis, and breast ultrasound. The diagnostic mammogram, tomosynthesis, and breast ultrasound fall within the diagnostic procedures and tests at an outpatient hospital 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 diagnostic mammogram, diagnostic digital breast tomosynthesis, and breast ultrasound you had at an outpatient hospital facility on March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on January 28, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on January 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips. 
 
You asked the Plan to provide coverage for additional routine transportation trips. The Plan denied your 
request. The Plan says the benefit maximum number of trips has been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the thyroid stimulating hormone (TSH) lab test (procedure code 84443) you received on April 2, 2021.
You asked the Plan to waive the copayment for the TSH test. You say that there should be no copayment for this test as it should be considered part of the lipid panel you had at the same time. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that thyroid testing is not part of the group of preventive lab services that are covered with a $0 copayment.
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 all other lab services.
You have been asked to pay a $10 copayment for the TSH test. Because your Plan has not designated TSH testing as one of the labs it will cover with a $0 copayment, the TSH test falls within the 'all other lab 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 thyroid stimulating hormone (TSH) lab test (procedure code 84443) you received on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wound care supplies provided on 
February 14, 2020. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the items provided. 
 
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% 
coinsurance for durable medical equipment and supplies.  
 
You have been asked to pay $34.34 (Plan allowed amount of $171.66 x 20% coinsurance) for the medical 
supplies provided.

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 the wound care supplies provided on  
February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 10, 2020 to 
September 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 22612 is not supported. 
 
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 22612 is arthrodesis, posterior or posterolateral 
technique, single level; lumbar (with lateral transverse technique, when performed). 
 
We find that CPT code 22612 is not supported in the medical record. Specifically, the services were not billed 
with the required device. 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 surgical services 
rendered on September 10, 2020 to September 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ambulance service, advanced life 
support, emergency transport, level 1 (A0427) provided March 4, 2021. 
 
You asked the Plan to reduce the copayment for the ambulance transport. You say that you expected a $90 
copayment for the ambulance service. The Plan denied your request. The Plan says the copayment was applied 
correctly based on your ambulance service benefit. 
 
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 $300 
copayment for Ambulance services.  
 
You have been asked to pay a $200 copayment for the ambulance transport. The Plan contract specifies that the Worldwide emergency care transportation copayment applies to emergency care outside the United States and 
its territories. This ambulance transport was provided within the United States and therefore falls within the 
Ambulance services benefit category. This means that you have been asked to pay less than or equal to 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 ambulance service, advanced life support, emergency transport, level 1 (A0427) provided March 4, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that you need the additional rides above the 30 one-way rides to locations other than your primary care provider. The Plan denied your request. The Plan says you have exhausted the Plan's benefit of 30 one-way rides per year to other health care related locations.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 30 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and coinsurance for the oxygen equipment you rented from January 14, 2021, to May 14, 2021.
You asked the Plan to waive the deductible and coinsurance for the oxygen equipment. You say that you have never had to pay for your oxygen supplies in the past. The Plan denied your request. The Plan says you were charged this deductible and coinsurance correctly. The Plan says that if you rented oxygen equipment prior to your enrollment, you are still responsible for the cost sharing listed in your Evidence of 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 20% coinsurance for durable medical equipment and supplies and that the deductible of $250 applies to this
equipment. You have been asked to pay your $250 deductible and 20% coinsurance for the oxygen equipment. The oxygen equipment falls within the durable medical equipment and supplies benefit category. This cost sharing applies regardless of whether or not you had this equipment prior to enrolling in the Plan. 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 deductible and coinsurance for the oxygen equipment you rented from January 14, 2021, to May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray represented by code 71045 provided on March 24, 2021.
You asked the Plan to pay for code 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as 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, we have confirmed that code 71045 has a bundled relationship with code 36558 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray represented by code 71045 provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your needs do not require an interdisciplinary approach to rehabilitation care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that you are being treated conservatively as an outpatient for an ankle fracture after a fall. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the primary care office visit you had on April 14, 2021.

You asked the Plan to waive the copayment for the primary care office visit. You say that this was a wellness visit so there should be no charge. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for primary care office visits. 

You have been asked to pay a $10 copayment for the primary care office visit. Billing records from this date of service show that in addition to your annual wellness visit, you had an office visit unrelated to the wellness exam. Records indicate that you were evaluated for anemia and hip pain, which is not part of a regular wellness exam. That is why a separate office visit copayment applies. 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 primary care office visit you had on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clinic visit provided on March 24, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for a clinic visit. You say that you would like this claim reprocessed and paid due to 
medical necessity. The Plan denied your request. The Plan says you would like this claim reprocessed and paid. 
 
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 a clinic visit provided on March 24, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on April 5, 2021 by a non-network provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 physician services provided on April 5, 2021 by a non-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries you had at an 
ambulatory surgery center on March 3, 2021, and March 9, 2021. 
 
You asked the Plan to waive the copayments for the cataract surgeries. You say that you wish to appeal these 
claims. The Plan denied your request. The Plan says you were charged these 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 $175 
copayment for ambulatory surgical center visits.  
 
You have been asked to pay a $175 copayment for each of the cataract surgeries. 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 copayments for the cataract surgeries you had at an ambulatory surgery center on March 3, 2021, 
and March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wig, any type (A9282) purchased March 5, 2021. 
 
You asked the Plan to pay for a wig. You say that you suffer from alopecia. Please reconsider your payment 
request. You only purchase a replacement every 2 years when the prosthesis is too worn to help. The Plan 
denied your request. The Plan says the enrollee does not meet the benefit requirements. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are 
ordered by a physician. The Plan follows these same rules. 
 
In this case, the health plan covers wigs when due to hair loss from chemotherapy. The enrollee has hair loss 
due to alopecia. although the wig may be appropriate, the enrollee does not meet the criteria. Therefore, we 
decided that the Plan does not have to pay for a wig, any type (A9282) purchased March 5, 2021.