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

We decided that the Plan does not have to waive the copay for the electrocardiogram provided on March 11, 2021.

You asked the Plan to waive the copay for the services provided. You say that you have never paid for an electrocardiogram before. The Plan denied your request. The Plan says the copay was applied per your plan 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). Your contract with the Plan clearly says that you must pay a $10 copay per day for Medicare-covered x-rays.

You have been asked to pay $6.96 copay for the services provided. Because the amount is less than the $10 copay, you were charged the lesser amount. The services are not included in the annual physical exam. 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 copay for the electrocardiogram provided on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (root canal) services (D3310, D3320).
You asked the Plan to pre-approve endodontic therapy. You say that these services are necessary and without them, you will lose your teeth. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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. The Plan does not cover endodontic services. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (root canal) services (D3310, D3320).
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 for the enrollee
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member does not have complex nursing or medical needs requiring a resource intensive inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for coronary artery
bypass grafting and aortic valve replacement. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visits provided on February 2, 2021 to March 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visits. You say that this doctor is the only ophthalmologist in Hawaii and the enrollee was unaware that a preauthorization would be required. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visits provided on February 2, 2021 to March 2, 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee can tolerate and would benefit from intensive rehabilitation therapy services and care. The Plan denied your request. The Plan says the enrollee's skilled therapy and nursing needs could be met in a lower level of 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 in the Medicare rules section.
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 that 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 does require physical and occupational therapy, but there is no documented 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. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98941) provided on May 6, 2021 to May 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that this provider should be on the list of doctors because he is the best in this area. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the chiropractic services (98941) provided on May 6, 2021 to May 17, 2021 by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pay for IRF care. You say that admission to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says criteria for admission to an IRF have not been met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of 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 in the Medicare rules section. 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 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 that 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 does require physical and occupational therapy, but there is no documented 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. Medically necessary services can be provided in a different level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87496, 87641, 87581, 87486, 87541, 87500, 87651, 87640, 87653, 87561, 87498, 87556, 87481 and 87798) provided on October 6, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87496, 87641, 87581, 87486, 87541, 87500, 87651, 87640, 87653, 87561, 87498, 87556, 87481 and 87798) provided on October 6, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services received on February 22, 2021.
You asked the Plan to pay for the services. You say that the hospital is in network, and the labs were ordered by the doctor for the office visit. The Plan denied your request. The Plan says that the claim has processed correctly.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the services by a contract provider. The hospital that ordered the laboratory services is a contract provider with the plan. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services received on February 22, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided December 30, 2020.
You asked the Plan to pay for the diagnostic services. You say that the procedure was performed at the request of the referring doctor, as the enrollee's medical condition proved the medical necessity for the services. Please reconsider this denial and reprocess the claim for payment. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. The claim should be billed with the appropriate code for these services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 71046 is radiologic examination, chest.
We find that CPT code 71046 is not supported in the medical record. Specifically, the claim cannot be billed as a screening as it needs a corresponding diagnosis code. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the radiologic examination, chest (71046) provided December 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided to the enrollee on December 7, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. There is a clinical summary in the medical records that includes patient demographics and medical diagnosis (pain in lower back) by attending physician. In the records, the referring provider is different than listed. However, there are no claims from May 1, 2018, through May 24, 2021, submitted to the Plan by either for the enrollee. There is also no proof of delivery in the submitted medical records. There were no claims submitted by the listed referring provider to support the need for a lumbar brace. Based on these reasons the claim processed correctly; therefore, no changes can be made to this claim. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (CPT code L0650) provided to the enrollee on December 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 30, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the ambulance refused to transport the enrollee to the hospital. The Plan denied your request. The Plan says Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, there is no Medicare-covered service.
The Plan follows Medicare rules. Medicare rules say that if an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. The rules also say that this requirement is waived in cases where an individual would have been transported to a covered destination, but such transport did not occur as a result of community-wide EMS protocols in place due to the COVID public health emergency. 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 ambulance response and treatment with no transport. Our reviewer says that the non-transportation services do not meet coverage criteria. Our physician reviewer found the documentation does not support that the EMS protocol had anything to do with the decision for the enrollee to not be transported, which was entirely the choice of the enrollee and his family. 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 ambulance response and treatment with no transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on January 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that LDCT for lung cancer screening is covered when specific criteria are met.
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 these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a history of renal cell carcinoma and has undergone treatment. The record suggests that the enrollee should be undergoing surveillance chest CT for the cancer. A separate CT scan to screen for lung cancer is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heavy-duty wheeled walker (CPT code E0149) for the enrollee.
You asked the Plan to pre-approve the walker. You say that the enrollee has a diagnosis which significantly impacts the enrollee's ability to ambulate safely. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan states it does sound like the enrollee would benefit from a walker that meets their needs better. The Plan states they would authorize a new walker for the enrollee, but the Plan would not be able to authorize a heavy-duty walker based on the weight requirement as per Medicare rules.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the walker have not been met. This enrollee would not meet criteria for a heavy-duty walker as they do not weight more than 300 pounds. The rules state a heavy-duty walker
(E0148, E0149) is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds. If an E0148 or E0149 walker is provided and if the beneficiary weighs 300 pounds or less, it will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the heavy-duty wheeled walker (CPT code E0149) for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services received on February 12, 2021.
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you feel you should not have to pay an additional fee to complete the procedure you received. The Plan denied your request. The Plan says the services were processed correctly per your plan 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). Your contract with the Plan clearly says that you must pay a $300 copayment for each Medicare-covered outpatient surgical service provided in an outpatient hospital setting. You have been asked to pay a $300 copayment for the outpatient surgery services. The outpatient surgery services fall within the outpatient surgery 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 outpatient surgery services received on February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for the vision care services (92133, 92015, 92014, V2702, V2303) received March 30, 2021.
You asked the Plan to provide additional reimbursement for the vision care services. You say that the Plan said you would receive reimbursement for the requested services. The Plan denied your request. The Plan says your reimbursement is limited to $135 every two years.
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 these services and provides up to $135 of reimbursement every two years. We looked at the file and the Plan's rules. The Plan has provided $158.16 of reimbursement for the requested routine vision care services. This amount is greater than the Plan's limit of $135 every two years. Any amount over what has been reimbursed is your responsibility for payment. Based on this information, we decided that the correct cost share has applied to this claim. Therefore, we decided that the Plan does not have to provide additional reimbursement for the vision care services (92133, 92015, 92014, V2702, V2303) received March 30, 2021.