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

We decided that the Plan does not have to pay for the laboratory services.

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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Computed tomographic (CT) scan of blood vessel of head with contrast (70496) and the CT scan of blood vessel of neck with contrast (70498).

You asked the Plan to waive the copayment for the CT scan of the head and the CT scan of the neck. You say that you were not told by the provider that there would be two separate copayments. The Plan denied your request. The Plan says the copayments were 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 $110 copayment for each Medicare-covered radiological diagnostic service, not including Xrays, performed in a physician's office or at a free-standing facility.

You have been asked to pay a total of $220 for the CT scan of the head and the CT scan of the neck ($110 copayment x 2 scans). CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan of blood vessel of head with contrast (70496) and the CT scan of blood vessel of neck with contrast (70498).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided by an OON provider.

You asked the Plan to pay for the periodic oral evaluation. You say that you believed this facility was in-network. The Plan denied your request. The Plan says the service was rendered by an OON provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided by an OON provider.
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 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 COVID-19 pneumonia. Medical conditions are stable. There are no medical needs requiring
inpatient admission. 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 medical record documents a need for physical and occupational
therapy, it does not document a need for an intensive 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office services provided by an out of network (OON) provider.

You asked the Plan to pay for outpatient office services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were self-referred.

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 outpatient office services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided by an out of network (OON) provider.

You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and paid based on medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained.

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 dermatology services provided by an out of network (OON) provider.
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 you have an open wound and cannot put weight on
it. 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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
infected diabetic foot ulcers and had partial right forefoot amputation. Medical conditions are stable. There are
no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a
reasonable expectation that you 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced prosthetic foot.

You asked the Plan to pre-approve an advanced foot. You say that you would benefit from an advanced foot.
The Plan denied your request. The Plan says the requested foot exceeds your needs.

The Plan follows Medicare rules. Medicare rules say that a records must document the beneficiary's current
functional capabilities and his/her expected functional potential.

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 an advanced foot. Our physician
reviewer found that the medical records do not support that you have the ability to traverse most environmental
barriers, or have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple
locomotion. The requested advanced foot is not medically reasonable and necessary and appears to exceed your
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 an advanced foot have not been met. Therefore, we decided that the Plan does
not have to pre-approve an advanced prosthetic foot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the specialist visit and eye refraction you had on August 17,
2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says you are responsible for
the cost share.

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 specialist visits with a $40 copayment. The Plan does not cover eye refractions
covered by a specialist who is not network vision provider.

We looked at the file and the Plan's rules. The requested vision services were provided by a specialist who is
not a network vision provider. This means that you are responsible for the $40 specialist copayment. This also
means that the refraction is not a covered benefit. Therefore, we decided that the Plan does not have to pay for
the specialist visit and eye refraction you had on August 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the imaging services you had on May 4,
2020.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible
for the cost share.

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 each basic imaging service.

Review of the file shows that you had an ultrasound and diagnostic mammography on May 4, 2020. You have
been asked to pay a $45 copayment for each of the services. The services 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 imaging services you had on
May 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy sessions, 60 minutes (90837) provided by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy sessions. You say that you have appealed this case for 6 months while continuing to see the enrollee in good faith. The appeal was granted and all payment rendered. You have now received continued denials of further treatment. The Plan denied your request. The Plan says this provider type is not eligible in the Medicare program.

The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare As a member of the PPO plan you can receive your care from either an in-network provider or an out-of-network provider.

The requested provider in this case is a licensed professional counselor. Licensed professional counselors are not eligible to participate in the Medicare program. 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 individual psychotherapy sessions, 60 minutes (90837) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that these services were medically necessary. The
Plan denied your request. The Plan says prior authorization was not obtained for these services to be provided
out-of-network. The Plan says that there are in-network providers available 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 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 physician services provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular gene panel (81407, 81408, 81439).

You asked the Plan to pay for a cardiovascular gene panel. You say that this service is supported by the medical records. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

We looked at the file and Medicare rules. The test at issue is considered a CV risk assessment panel and is not covered. Based on this information, we decided that Medicare rules for coverage of a cardiovascular gene panel have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular gene panel (81407, 81408, 81439).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport services.

You asked the Plan to pay for the ambulance response and treatment with no transport services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that the insurance verifier contacted the Plan and was advised that this provider was in-network with the enrollee's plan. The Plan denied your request. The Plan says the treating provider has chosen to Opt Out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of intrauterine device (IUD) (58300) Levonorgestrel-releasing intrauterine contraceptive system (J7297).

You asked the Plan to pay for the insertion of IUD. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of IUD have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of intrauterine device (IUD) (58300) Levonorgestrel-releasing intrauterine contraceptive system (J7297).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit.

You asked the Plan to waive the copayment for the emergency room visit. You say that you do not think you should have any obligation for this claim. The Plan denied your request. The Plan says the copayment is only waived if you are admitted to the hospital within 24 hours for the same condition. You were not admitted to the hospital.

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 an $80 copayment for emergency care.

You have been asked to pay an $80 copayment for the emergency room visit. The emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outer surface covering for a lower leg prosthesis.

You asked the Plan to pre-approve an outer covering. The Plan denied your request. The Plan says the records
do not show you would be using your leg in very harsh conditions.

The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems are for
protection against unusually harsh environmental situations where it is necessary to protect the lower limb
prosthesis.

We looked at the file and Medicare rules. The records provided do not indicate that you need protection against
an unusually harsh environment. The records do not show that the covering that is already included is not able
to meet your needs. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pre-approve an outer surface covering for a lower leg
prosthesis.
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 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 knee pain and a sacral decubitus ulcer. Medical conditions are stable. There are no medical
needs requiring inpatient admission. 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 medical record documents a need for physical and
occupational therapy, it does not document a need for an intensive 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 IRF admission and services.