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

We decided that the Plan does not have to pre-approve the medical services to be provided by the out-of-network provider.
You asked the Plan to pre-approve allergy consultation. You say that there are no allergists in-network that can test for your allergies. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for negative pressure wound therapy electrical pump, stationary or portable (CPT Code E2402) provided from January 1, 2019 through February 19, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you were not informed of the coinsurance in a timely manner and you believe you should not have a cost-share for the January and February 2019 DME. The Plan denied your request. The Plan says the claims were processed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME from January 1, 2019 through February 19, 2019. Your EOC clearly states, enrollees must pay 20% coinsurance for DME and related supplies. Therefore, you are asked to pay 20% coinsurance for the DME. 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 negative pressure wound therapy electrical pump, stationary or portable (CPT Code E2402) provided from January 1, 2019 through February 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to enrollee on January 2, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is:CPT 99152: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.CPT 99153: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; each additional 15 minutes intraservice time (List separately in addition to code for primary service) We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the service at issue in this case were not coded correctly. Our physician reviewer found there is no documentation of the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status during the procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for moderate sedation services (CPT 99152) provided to enrollee on January 2, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 25, 2019 by an out of network provider.You asked the Plan to pay for the outpatient mental health services. You say that the provider goes to the facilities where the services are requested and oftenrenders necessary services prior to the verification of insurance. The Plan denied your request. The Plan says the services provided to the member were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 April 25, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lipid panel screening test provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the lipid panel screening test. The Plan denied your request. The Plan says screening tests are 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, the lipid panel screening test, 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 lipid panel screening test provided to the enrollee on August 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the clinical documentation provided supports the need for LTACH care.The Plan denied your request. The Plan says the enrollee's care can be provided in the current inpatient hospital.The Plan must follow Medicare rules. The rules saythat 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 enrollee's current needs include mechanical breathing support, IV antibiotic medications, IV steroids, and wound care in an acute care facility. The enrollee's vitals are unstable with labored breathing and high blood pressure, making transfer unreasonable. Also, there was no documented proposed services which were not already available and covered in the current setting to justify transfer to LTACH. There was no indication acute care treatment would likely span more than 25 days.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 11, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on April 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran injection provided on July 9, 2019.You asked the Plan to waive the copayment foran injection. You say that you have never had to pay for your injections before. You say that you are on a fixed income and cannot afford this copayment.The Plan denied your request. The Plan says the correct copayment has been applied.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 $350 copayment for outpatient surgery. You have been asked to pay a $350 copayment for an injection. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based onyour 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 foran injection provided on July 9, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tetanus and diphtheria toxoids vaccine (90714) provided on August 29, 2019.You asked the Plan to pay fora tetanus and diphtheria toxoids vaccine. You say that this should be covered as a preventative service.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a tetanus and diphtheria toxoids vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a tetanus and diphtheria toxoids vaccine.Therefore, we decided that the Plan does not have to pay fora tetanus and diphtheria toxoids vaccine (90714) provided on August 29, 2019.Benefits for a tetanus and diphtheria toxoids vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve repair of foot tendon.
You asked the Plan to pre-approve repair of foot tendon. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 repair of foot tendon. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found it is documented in the progress note that you suffer from a painful avulsion fracture of the fifth metatarsal base left side. You have failed conservative treatments including nonweightbearing, immobilization, and shoe gear modification. The treatment plan offered by the surgeon advises that they will remove the fracture fragment and repair/excise any hypertrophied tissue. This will necessitate re-anchoring of the peroneal tendon to the fifth metatarsal base. Therefore, the documentation supports that the repair of the foot tendon is standard of care for the treatment of your condition. It is medically reasonable and necessary for you to have the repair of foot tendon as requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repair of foot tendon have been met. Therefore, we decided that the Plan has to pre-approve repair of foot tendon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided while admitted on March 6, 2019.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The contract also says that skilled nursing facility services require prior authorization. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 forservices on March 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 31, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that  The Plandenied your request. The Plan says that the claim 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 $200 copayment for Ambulance services. You have been asked to pay $200 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 forthe ambulance transport provided on August 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 9, 2019.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the ordering provider was also out of network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. The services were ordered by a non-plan provider. 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 lab services provided to the enrollee on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the hospital outpatient clinic visit provided on June 25, 2019.
You asked the Plan to reduce the copayment for the hospital clinic visit. You say that this visit was with a primary care physician at MCHS Red Center and should be covered as an office visit instead of an outpatient hospital copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment per visit for outpatient hospital services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $20 copayment for the outpatient hospital clinic visit.
You have been asked to pay a $18.35 copayment for the hospital clinic visit. The hospital clinic visit falls within the "Outpatient hospital services" benefit category. The medical record shows you were seen for a follow-up at an outpatient hospital.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the hospital outpatient clinic visit provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's medical condition is stable, and the medical complexity of care is low.
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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 26, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the ordering/referring provider are not a network providers with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2019 by out of network provider. You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 services at issue in this appeal. 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 July 1, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for hydration infusion provided from May 13, 2019 to May 14, 2019.
You asked the Plan to pay for the hydration infusion. The Plan denied your request. The Plan says non-participating providers are required to furnish necessary information to the health plan when requested.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for hydration infusion provided from May 13, 2019 to May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health care provided to the enrollee on June 11, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 services at issue in this appeal. 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 outpatient mental health care provided to the enrollee on June 11, 2019.