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

We decided that the Plan does not have to pay for psychotherapy services provided on January 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says 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 psychotherapy services provided on January 25, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 was admitted with respiratory failure due to pneumonia. The enrollee is
no longer on a ventilator. The enrollee continues to receive acute care services, and these have not been denied.
The medical record does not indicate that the enrollee requires services that they are not currently receiving but
that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The
requested service cannot be recommended.
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-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long-term care (LTC) 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 13, 2020, to March 20, 2020.
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 had network providers
available who could have provided 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 services provided by an out-of-network provider on March
13, 2020, to March 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET scan provided on January 29, 2021.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used. We looked at the file and Medicare rules. The PET scan in question was billed with diagnosis code C67.9. This
is not an appropriate diagnosis code to bill for a PET scan. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the PET scan provided on January 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) and to pay more for the crown (D2751) provided on January 5, 2021.
You asked the Plan to pay for the prefabricated post and core or pay more for the crown. You say that you would like your second quarterly allowance to be used toward these services. The Plan denied your request. The Plan says the maximum allowed for your quarterly benefit has 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 Plan offers up to a $400.00 allowance for covered comprehensive dental services every quarter. The contract says that after Plan paid benefits for comprehensive dental services, you are responsible for the remaining costs. The record shows that you met the annual maximum benefit while processing this claim for the January 5, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prefabricated post and core in addition to crown (D2954) and to pay more for the crown (D2751) provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for podiatry services provided on December 11, 2020, and December 22, 2020.
You asked the Plan to waive the copayments for podiatry services. You say that you feel that the physician should have referred you to another provider. 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 $40 copayment for podiatry services. You received podiatry services on December 11, 2020, and December 22, 2020. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $80. You have been asked to pay the total copayment amount of $80 for podiatry services. Podiatry services fall within the podiatry 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 copayments for podiatry services provided on December 11, 2020, and December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to refund the copayment for the specialist office visit provided on January 12, 2021.
You asked the Plan to refund the copayment for the specialist office visit. You say that you would like a full refund from the physician. The Plan denied your request. The Plan says the provider rendered the service and billed the plan for the services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for Physician Services. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the Physician 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 refund the copayment for the specialist office visit provided on January 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99233) and the prolonged service in the inpatient or observation setting (99356) provided on November 24, 2020.
You asked the Plan to pay for the evaluation and management services. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify
the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on November 19, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent
hospital care (99233) and the prolonged service in the inpatient or observation setting (99356) provided on
November 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on December 4, 2020 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that 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 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 domiciliary or rest home visit provided on December 4, 2020 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy and physical therapy provided on January 1, 2021, to January 29, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for occupational therapy and physical therapy. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that the ordering physician is 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 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 occupational therapy and physical therapy
provided on January 1, 2021, to January 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance services and the emergency room visit provided on January 31, 2020.
You asked the Plan to waive the copayments for the ambulance services and the emergency room visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received ambulance services and an emergency room visit on the date of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $250 copayment for Ambulance services and a $90 copayment for Emergency care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received ambulance services on January 31, 2020. You have been asked to pay a $160 copayment for the ambulance services, which is less than the contracted $250 copayment amount. The ambulance services fall within the Ambulance services benefit category. The file shows you received an emergency room visit on January 31, 2020. You have been asked to pay a $90 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 amounts 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 copayments for the ambulance services and the emergency room visit provided on January 31, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency department visit (99283) provided November 6, 2020.
You asked the Plan to waive the copayment for the emergency visit. You say that you were admitted 3 times in November. You were admitted each time and should not be charged this $90. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $90 copayment per visit. You have been asked to pay $90 copayment for the emergency visit. The emergency 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 department visit (99283) provided November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar pain relief services defined by codes 64635 and 64636.
You asked the Plan to pre-approve the lumbar pain relief services. You say that the service is required. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage.
The Plan follows Medicare rules. Medicare rules say that 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 lumbar pain relief services. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no documentation of the percentage of pain relief achieved by these blocks. Therefore, the request does not meet Medicare coverage criteria. 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 lumbar pain relief services have not been met. Therefore, we decided that the Plan does not have to pre-approve the lumbar pain relief services defined by codes 64635 and 64636
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the group psychotherapy provided on November 30, 2020.
You asked the Plan to pay for the group psychotherapy. You say that you were unable to successfully obtain an authorization for the enrollee's services. You also say that the enrollee met medical necessity and the services should be covered. The Plan denied your request. The Plan says payments may not be made for services for individuals who have been committed under penal statute.
The Plan must follow Medicare rules. Medicare rules say that payment may not be made for services furnished without charge to individuals who have been committed under a penal statute. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the group psychotherapy have not been met. Therefore, we decided that the Plan does not have to pay for the group psychotherapy provided on November 30, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 8, 2021 by an out-ofnetwork
(OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says the rendering physician is out-of-network. The Plan says that 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 an office visit provided on April 8, 2021 by an
out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that it is the responsibility of the facility to obtain authorization. The Plan denied your request. The Plan says the claim correctly denied.
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 had network providers available who could have provided 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 office visit provided on February 11, 2021 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 an electrocardiogram (EKG) provided on April 2, 2021.
You asked the Plan to waive the copayment for EKG. You say that this was a routine electrocardiogram and you should be covered at 100%. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copayment for EKG. You have been asked to pay the allowed amount of $14.80, which is less than the $30 copayment for EKG. EKG 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 electrocardiogram (EKG) provided on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82565, 84132, 85014, and 85018 provided on February 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 82565, 84132, 85014, and 85018 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of creatinine; blood; therefore, code 82565 cannot be verified. The documentation submitted did not include documentation of Potassium serum, plasma or whole blood;
therefore, code 84132 cannot be verified.
The documentation submitted did not include documentation of blood count; hematocrit (Hct); therefore, code
cannot be verified.
The documentation submitted did not include documentation of blood count; hemoglobin (Hgb); therefore, the
billed service cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82565,
84132, 85014, and 85018 provided on February 22, 2021.