Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary. The Plan denied your request. The Plan says the member's nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach for delivery of rehabilitation care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 there is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at an SNF level or likely through home based and outpatient 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fully-electric hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your
request. The Plan says these are not a covered benefit, as the height adjustment feature is considered a
convenience item.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a fully-electric
hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided on November 13, 2019.You asked the Plan to waive the copayment for radiation treatment. You say that the cost is a lot. You say that you want help with the copayment.The Plan denied your request. The Plan says the copayment 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 $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service.You have been asked to pay a $60 copayment for the radiation treatment. The radiation treatment falls 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 radiation treatment provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391) provided on October 23, 2019.You asked the Plan to pay for the dental services. You say that this was a partial filling to keep from having a root canal or tooth removal later. You also say that this service was preventive.The Plan denied your request. The Plan says fillings are not a covered service.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, a filling is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the filling (D2391) provided on October 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulatory blood pressure monitor (A4670) provided on October 29, 2019. 
 
You asked the Plan to pay for the ambulatory blood pressure monitor. You say that this was a medically necessary claim. The Plan denied your request. The Plan says coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that ABPM must be performed for at least 24 hours to meet coverage criteria and is only covered for those patients with suspected white coat hypertension. We looked at the file and Medicare rules. In this instance, there is no evidence of a diagnosis of white coat hypertension or monitoring for at least 24 hours. Based on this information, we decided that Medicare rules for coverage of the ambulatory blood pressure monitor have not been met. Therefore, we decided that the Plan does not have to pay for an ambulatory blood pressure monitor (A4670) provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided by doctor on November 20, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that this was a follow-up visit and you disagree with the charges.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 $30 copayment for each specialist visit. You had a specialist visit on November 20, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit 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 thePlan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided by doctor on November 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a foot x-ray (73630) provided on August 6, 2019. 
 
You asked the Plan to pay for the foot x-ray. You say that per CMS, you are not able to bill globally. The Plan denied your request. The Plan says when a provider under the same TIN performs both the professional and technical components of a code, they need to bill globally. 
 
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 73630 is not supported in the record. Specifically, when a provider renders both the technical and professional component of a claim, it is billed globally. Based on this information, we decided that Medicare rules for coverage of the foot x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a foot x-ray (73630) provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient hospital services provided in relation to your dental extractions on February 19, 2019.
You asked the Plan to pre-approve the outpatient hospital services. You say that you were never told about the limits of what can be covered under medical rather than dental. You feel that this was a medically necessary service and you did everything you could to get the Plan to help pay for it. The Plan denied your request. The Plan says payment was made for the hospital anesthesia services. However, the remaining facility charges are not covered by your Plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, and removal of teeth and supporting structures of the teeth. This is the Medicare definition of dental services. Although your condition may have medical consequences, the services are defined as dental, which means they are excluded from coverage. Although your plan does cover some dental care, this does not include charges billed by an outpatient hospital. Therefore, we decided that the Plan does not have to pre-approve the outpatient hospital services provided in relation to your dental extractions on February 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory testing. You say that this service was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 September 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not have waive the copayment forradiation therapy provided on December 5, 2019.You asked the Planwaive the copayment forradiation therapy. You say that you need help paying this.The Plandenied your request. The Plansays this copayment is a contractual obligation.The rulessay 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 $60 copayment for each Medicare-covered radiationtherapy service.You have been asked to pay $60 for radiation therapy.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 copayment forradiation therapy provided on December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services 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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Contact lens gas permeable (V2531 RT) contact lens fitting (92310) provided October 25, 2019. 
 
You asked the Plan to pay for the vision services. You say that the contacts is a medical necessity and not cosmetic. Your glasses will still be worn as the contact is only for the right eye. You are on a fixed income and the costs is too much. The Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
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 one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. coverage for eyeglasses or contact lenses is only covered after each cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for Contact lens gas permeable (V2531 RT) contact lens fitting (92310) provided October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 22, 2019 to May 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on May 22, 2019 to May 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary. You say that these services are provided in good faith of reimbursement. The Plan denied your request. The Plan says no prior authorization was obtained. There are multiple in-network providers available within 30 miles of the member's residence that could have rendered 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 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 an office visit provided on October 17, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on April 23, 2018 and April 24, 2018.
You asked the Plan to pay for hospital services provided to the enrollee on April 23, 2018 and April 24, 2018.. You say that this should be paid for. The Plan denied your request. The Plan says the claim was received past the allowed 12 month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for hospital services provided to the enrollee on April 23, 2018 and April 24, 2018 was not filed until October 14, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on April 23, 2018 and April 24, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 7, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ECG, the echocardiography, or the
imaging supply provided on September 9, 2019.
You asked the Plan to waive the cost share for the ECG, an echocardiography, and the imaging supply. You
say that you did not have the services done and they were rescheduled to October 10, 2019. 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 $400
copayment for each Medicare-covered diagnostic procedure and test in an outpatient facility and 20%
coinsurance for disposable medical supplies.
You have been asked to pay a total of $346.63 for the ECG, the echocardiography, and the imaging supply. The
ECG, the echocardiography, and the imaging supply falls within the "Outpatient diagnostic tests and
therapeutic services and supplies" benefit category. The record shows you were present at the facility to receive
the services.
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 cost share for the ECG, the echocardiography, or the imaging supply
provided on September 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on August 30, 2019.
You asked the Plan to waive the copayment for an MRI. You say that you were told that you would not owe a copayment and you are unhappy with the customer service you received from the Plan. 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 $0 copayment for diagnostic radiology services provided by a primary care physician and a $200 copayment when provided by any other provider. You have been asked to pay a $200 copayment for an MRI. An MRI falls 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 an MRI provided on August 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 14, 2019.
You asked the Plan to pay for the knee orthoses (L1833) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says the office visit records do not mention knee pain, treatment, or need for the orthotics.
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. The records do not support medical necessity. Based on this information, we decided that Medicare rules for coverage of the knee orthoses (L1833) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 20, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says nonemergent,
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 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 psychotherapy services provided on August 20, 2019.