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

We decided that the Plan does not have to pay for the medical services provided on September 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services were medically necessary so the claim should be paid. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 the medical services provided on September 17, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on July 8, 2020 and August 26, 2020.
You asked the Plan to waive the copayment for the x-rays. You say that you should not have these copayments. The Plan denied your request. The Plan says you were charged the 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 $45 copayment for outpatient diagnostic tests. You have been asked to pay a $45 copayment for the x-rays. The x-rays fall within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the x-rays provided on July 8, 2020 and August 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forchemodenervation and does not have to waive the coinsurance for Medicare Part B drugs provided on June 8, 2020.You asked the Plan to waive the copayment forchemodenervation and to waive the coinsurance for Medicare Part B drugs. You say that you have never been charged 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 $50 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.You received chemodenervation on June 8, 2020. Therefore, you are responsible to pay the $50 copayment. You received Medicare Part B drugs provided on June 8, 2020. The total allowed amount is $1,222 and 20% of that is $244.40. The total amount you owe is: $50 + $244.40 = $294.40.You have been asked to pay the total amount of $294.40 chemodenervation and Medicare Part B drugs. Chemodenervation falls within the physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 forchemodenervation and does not have to waive the coinsurance for Medicare Part B drugs provided on June 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services.You asked the Plan to pre-approvethe LTACH services. You say that the stay is medically necessary.The Plandenied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not appear to show evidence of multiple unsuccessful weaning attempts to suggest LTACH would be warranted. The patient requires additionalshort-term acute care services to perform more weaning attempts and to determine long-term needs. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer may be considered at a later date when more appropriate.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approveLTACH services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to hold you harmless for laboratory testing provided on April 30, 2020.
You asked the Plan to hold you harmless for lab test. You say that you have not been able to get this claim
adjusted and should not be responsible for the way it was processed. The Plan denied your request. The Plan
says that the denial of payment for this testing is correct.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician for this testing was in-network
or out-of-network with the Plan and the time this testing was ordered. The documentation submitted
does not include prior notice from the Plan that this testing would not be covered. Without this information, the
Plan has not shown that its decision to deny payment for this testing was correct or justified according to
Medicare rules. Therefore, we decided that the Plan has to hold you harmless for laboratory testing provided on
April 30, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for14 dental extractions (D7140 x 14) performed on June 2 to July 7, 2020.You asked the Plan to pay for14 dental extractions. You say that the enrollee was told when purchasing the plan that extractions and dentures were covered.The Plan denied your request. The Plan says rules for payment have not been met.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for14 dental extractions (D7140 x 14) performed on June 2 to July 7, 2020.Your complaint about the enrollee receiving erroneous or misleading information about benefitsis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a 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-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services with CPT code 99152 provided
on February 11, 2020.
You asked the Plan to pay for CPT code 99152. You say that the medical records support the billing of CPT
code 99152. The Plan denied your request. The Plan says the medical records do not support the billing of CPT
code 99152.
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 99152 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; initial 15 minutes of intraservice time, patient age
5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not
contain evidence that moderate sedation was performed with the presence of an independent trained observer.
Based on this information, we decided that Medicare rules for coverage of CPT code 99152 have not been met.
Therefore, we decided that the Plan does not have to pay for moderate sedation services with CPT code 99152
provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided in on August 25, 2020 by an
out of network (OON) provider in an OON assisted living facility.
You asked the Plan to pay for the medical services. You say that the assisted living facility called this provider
in to provide medically necessary care to this patient. The Plan denied your request. The Plan says neither the
provider or service nor the assisted living facility where the member resides is a contract provider with this
Plan. These services were unauthorized and are therefore non-covered.
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we
decided that the Plan does not have to pay for the medical services provided in on August 25, 2020 by an out of
network (OON) provider in an OON assisted living facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (low back) joint injection (CPT Code 27096).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the service is not 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request is not supported by physical exam or imaging. The request is not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (low back) joint injection (CPT Code 27096).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 26, 2020, by an OON provider.You asked the Plan to pay fornursing facility care. You say that the service provided was medically necessary to take care of the enrollee.The Plan denied your request. The Plan says rules for payment have not been met.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 anetwork 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 theseitems/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on May 26, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of servicesprovided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare will pay for an IRF admission when the services are reasonable and medically necessary. The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The patient must need active and ongoing treatment by more than one therapy discipline. One of the therapies must be physical therapy or occupational therapy. The patient must need and be expected to actively participate in and to benefit from an intensive rehabilitation therapy program. This intensive rehabilitation therapy program generally consists of at least three hours of therapy per day at least five days per week. The patient does not need to be expected to achieve complete independence in self-care nor be expected to return to his or her prior level of functioning. The patient must need supervision by a rehabilitation physician. The physician must see the patient at least three days per week throughout the stay. You can find these rules in the Medicare Benefit Policy Manual, Chapter 1, Sections 110.2 and 110.2.5 and at 42 CFR Section 412.622.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive the coinsurance forMethylprednisolone injection (J2920)  Ferumoxytol injection (Q0138)  therapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96374, 96375)  provided July 29, 2020.You asked the Plan waive the coinsurance forthe injection services. You say that you need these injectionsand cannot afford the coinsurance. You were unaware that you had a coinsurance.The Plan denied your request. The Plan says the claim was processed and the correct coinsurance was applied per the 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 Medicare Part B Prescription Drugs. You have been asked to pay $109.02 for the injection services. The injection services fall within the Medicare Part B Prescription Drugs 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 waive the coinsurance forthe Methylprednisolone injection (J2920)  Ferumoxytol injection (Q0138)  therapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96374, 96375)  provided July 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forhyaluronan or derivative, gel-one, for intra-articular injection, per dose (J7326) provided on August 10, 2020.You asked the Plan to waive the coinsurance forhyaluronan or derivative, gel-one, for intra-articular injection, per dose. You say that you were unaware there was a cost share.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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for hyaluronan or derivative, gel-one, for intra-articular injection, per dose. This service falls within the Medicare Part B prescription drugs 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 coinsurance forhyaluronan or derivative, gel-one, for intra-articular injection, per dose (J7326) provided on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 20, 2020, by an OON
provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that these medically necessary services
were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment
have not been met.
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 medical services provided on July 20, 2020, by
an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PBRT.
You asked the Plan to pre-approve PBRT. You say that the services are necessary. The Plan denied your request. The Plan says a review of the literature indicates that PBRT is not the standard of care for prostate cancer and Proton Beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial.
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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found per NCCN radiation compendium choices for definitive treatment are bracytherapy and external beam radiation proton beam is not listed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve PBRT.