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

We decided that the Plan does not have to pay for the Covid test provided on May 22, 2020.

You asked the Plan to pay for the Covid test. You say that you work in a skilled nursing facility and are in contact with a lot of high risk people. The Plan denied your request. The Plan says Medicare does not cover any kind of testing, including Covid, for employment verification or employment application.

The Plan follows Medicare rules. Medicare does not cover screening lab services for the purpose of employment. Medicare only covers lab services to detect possible disease for the purpose of treatment. In this case, but for the application requirement to your employment, it does not appear that you required a Covid test. Therefore, the Plan is not required to pay for this testing. Furthermore, outpatient diagnostic services require prior authorization. Therefore, we decided that the Plan does not have to pay for the Covid test provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for office outpatient visit (99215) provided on August 11, 2020.

You asked the Plan to waive the copayment for office outpatient visit. You say that the copay should be waived. The Plan denied your request. The Plan says the cost share was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 specialist copayment for Physician/Practitioner services, including doctor's office visits. 

You have been asked to pay a $35 specialist copayment for office outpatient visit. This service falls within the Physician/Practitioner services, including doctor's office visits 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 office outpatient visit (99215) provided on August 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the 
enrollee's treatment plan was no longer of any clinical benefit. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services from January 17, 2021, forward were requested. 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 continued services. Our physician reviewer found that active treatment was 
not taking place. 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. I am unable to find an individualized 
treatment plan, however the entire chart is not present. The enrollee was not shown to be a danger to herself or 
others. She was not showing any auditory or visual hallucinations, and was cooperative/compliant with 
treatment while not showing any threats to safety. Based upon review of the records, the enrollee does not meet 
the criteria for continued acute inpatient mental health treatment from January 17, 2021, forward. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient mental health services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on February 18, 2018 by an out of network (OON) provider.

You asked the Plan to pay for the OON radiology services. You say that you are in an assisted living facility and fell out of bed. You say that the facility ordered these x-rays and asked that the Plan help you with the bill. The Plan denied your request. The Plan says the provider who supplied the radiology services is 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 facility that ordered the radiology services from this provider is also 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 radiology services provided on February 18, 2018 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pelvis or hip joint surgery, hip orthosis, knee orthosis, and addition to lower extremity, and pay for the insulin injection provided from July 27, 2020, to July 29, 2020.
You asked the Plan to waive the copayment for the pelvis or hip joint surgery, hip orthosis, knee orthosis, and addition to lower extremity, and pay for the insulin injection. You say that you would like the charge for the insulin fully covered. You also say that you feel the copays for the medical equipment should be included in the surgery charges. The Plan denied your request. The Plan says the insulin injection is a self-administered drug, and is not covered by Medicare Part B. The Plan also says that the copayment amounts that you are being charged for the pelvis or hip joint surgery, hip orthosis, knee orthosis, and addition to lower extremity are correct. 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 Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers, and a $15 copayment for Prosthetic Devices and Related Supplies. The rules also say that Medicare Part B generally does not pay for self-administered drugs. You have been asked to pay a $100 copayment for the pelvis or hip joint surgery, and $15 copayments for the hip orthosis, knee orthosis, and addition to lower extremity. The pelvis or hip joint surgery falls within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The hip orthosis, knee orthosis, and addition to lower extremity fall within the Prosthetic Devices and Related 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. 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 waive the copayment for the pelvis or hip joint surgery, hip orthosis, knee orthosis, and addition to lower extremity, or pay for the insulin injection provided from July 27, 2020, to July 29, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT Code 70553) provided on July 22, 2020.You asked the Plan topay forthe MRI. You say that the claim should be paid.The Plan denied your request. The Plan says that the services are 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.We find that CPT code 70553 is supported in the medical record. Specifically, the services are supported with the medical records because a procedure report was provided. Based on this information, we decided that Medicare rules for coverage of the MRI have been met.Therefore, we decided that the Plan has to pay forthe MRI, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences (CPT Code 70553) provided on July 22, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe implantation of spinal neurostimulator electrodes (63650).You asked the Plan to pre-approvethe implantation of spinal neurostimulator electrodes. You say that this service is medically necessary.The Plan denied your request. The Plan says the criteria for spinal cord stimulation has not been met.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 implantation of spinal neurostimulator electrodes. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case and do not meet the relevant national coverage determination criteria. Our physician reviewer found this is a 73-year-oldman with chronic low back pain. 
The patient does not have an evidence-basedindication for spinal cord stimulation (SCS) and there is no psychological evaluationsubmitted for review.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 implantation of spinal neurostimulator electrodes have not been met.Therefore, we decided that the Plan does not have to pre-approvethe implantation of spinal neurostimulator electrodes (63650).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fourteen additional skilled nursing home health visits.
You asked the Plan to pre-approve fourteen additional skilled nursing home health visits. You say that this is
medically necessary. The Plan denied your request. The Plan says you do not require skilled nursing care.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 fourteen additional skilled nursing
home health visits. Our reviewer says that the requested home health visits are not medically necessary. Our
physician reviewer found there is no evidence in the submitted medical records that you currently have skilled
nursing needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of fourteen additional skilled nursing home health visits have not been met.
Therefore, we decided that the Plan does not have to pre-approve fourteen additional skilled nursing home
health visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe chest x-ray (71045). You say that you would like reconsideration because you believe you are in-network with the Plan.The Plan denied your request. The Plan says services for non-par providers in place of service 11 require priorauthorization and there no authorization on file for these services.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 providersonly 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 forthe medical services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for the eye refraction services (92015) provided on August 19, 2020.
You asked the Plan to hold you harmless for the eye refraction services. You say that the services should have been covered. The Plan denied your request. The Plan says that this service is normally not covered.
Medicare rules say that, for a service or item that is normally not covered, but could be covered under some conditions, the EOC alone is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. The Plan follows these rules. You received eye refraction services from a contract provider. The file does not show that the Plan provided notice that the eye refraction services would not be covered. The service at issue is an example of a service that is normally not covered but could be covered under certain circumstances. The EOC is therefore, not adequate notice of non-coverage in this case. Under Medicare rules, this means the eye refraction services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the eye refraction services (92015) provided on August 19, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe surgery service provided on January 31, 2020.You asked the Plan to waive the copayment forthe surgery service. You say that your doctor's office was under construction so you should not have a copayment for going to the Medical Center.The Plan denied your request. The Plan says the provider billed this procedure as a surgery code therefore 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 $300 copayment for Outpatient HospitalSurgical Service. You have been asked to pay a $119.42copayment for the operating room service. The operating room service falls within the Outpatient Hospital Surgical Service benefit category. The allowed amount for the surgery was less than your copayment which is why your copayment is less. 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 forthe surgery service provided on January 31, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit while the enrollee takes part in a clinical
trial.
You asked the Plan to pre-approve an office visit while the enrollee takes part in a clinical trial. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested
services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that services received while part of a clinical trial are
non-covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of an office visit while the enrollee takes part in a clinical trial have not been met. Therefore, we
decided that the Plan does not have to pre-approve an office visit while the enrollee takes part in a clinical trial.
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 would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicarerules. 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 wascorrect 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 for respiratoryfailure and pneumonia. The enrollee's medical conditions are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program provided in an IRF. The enrollee's care needs can be met at lower level of 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forunna boot strapping (29580) and the application of vein wound compression system (29581) provided on March 17, 2020, March 25, 2020, and April 1, 2020.You asked the Plan to waive the copayment forunna boot strapping and the application of vein wound compression system. You say that you believe you are being over charged.The Plan denied your request. The Plan says these services processed 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 $300 copayment for each Medicare-covered outpatient surgery service. You have been asked to pay a $300 copayment for each date of service of unna boot strapping and the application of vein wound compression system for a total of $900. These services are considered outpatient surgery servics.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 waivethe copayment forunna boot strapping (29580) and the application of vein wound compression system (29581) provided on March 17, 2020, March 25, 2020, and April 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Forteo 600 mcg/2.4 mL solution.
You asked the Plan to pre-approve Forteo. You say that this service is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the member's medical benefit.
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 Forteo 600 mcg/2.4 mL solution.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forhearing aids provided on June 26, 2020.You asked the Plan to pay forthe hearing aids. You say that at no time were you notified your referral had expired.The Plan denied your request. The Plan says you received non-coveredservices.The Plan must follow Medicare rules. Medicare rules say that Medicare does not cover hearing aids or related services.  We looked at the file and Medicare rules. The referral was for a diagnostic hearing evaluation not hearing aids. Though hearing aidsmay be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services.Therefore, we decided that the Plan does not have to pay forhearing aids provided on June 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapeutic exercises (97110), neuromuscular reeducation (97112), gait training therapy (97116) and swallowing function evaluation (92610) provided on September 2, 2020 to September 15, 2020 by an out of network (OON) provider.You asked the Plan to pay fortherapeutic exercises, neuromuscular reeducation, gait training therapy and swallowing function evaluation. You say that the services should be covered.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services with an out-of-network provider.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 forthe therapeutic exercises (97110), neuromuscular reeducation (97112), gait training therapy (97116) and swallowing function evaluation (92610) provided on September 2, 2020 to September 15, 2020 by an out of network (OON) provider