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

We decided that the Plan does not have to pay for the magnetic resonance imaging, of the brain (including brain stem); without contrast material (70553), the Gadobenate dimeglumine injection (A9577), and the pharmaceutical medication rendered by the out-of-network (OON) provider on April 22, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 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 magnetic resonance imaging, of the brain (including brain stem); without contrast material (70553), the Gadobenate dimeglumine injection (A9577), and the pharmaceutical medication rendered by the out-of-network (OON) provider on April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on April 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON services. You say that the facility is not required to obtain prior authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
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 evaluation and management services provided on April 12, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on May 10, 2021.

You asked the Plan to pay for the MRI. You say that documentation supports the billed code. The Plan denied your request. The Plan says the billed diagnoses are not covered.

The Plan must follow Medicare rules. Medicare rules say that breast imaging is only covered under certain medical indications.

We looked at the file and Medicare rules. The records show that the test was ordered due to a family history of breast cancer in a first degree relative. The records do not show the test was performed due to signs, symptoms, or abnormal findings. This testing is not covered for screening purposes. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the OON provider on
April 22, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of
network, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service 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 this service. Therefore, we decided that the Plan
does not have to pay for the office visit (99214) rendered by the OON provider on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided from September 18, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that inpatient mental health care is medically necessary. The Plan denied your request. The Plan says inpatient mental health care is no longer medically reasonable and necessary for your condition.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient mental health care. Our reviewer says that this inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found that you did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to herself or others as you did not have auditory hallucinations or visual hallucinations and were cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. Based upon review of the records provided you do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of September 18, 2021, forward as you were not shown to be a danger to yourself or others. You were not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. You were not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care provided from September 18, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (36415, 85025, 80048, 84484)
rendered by the OON provider on July 10, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without 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 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 laboratory services (36415, 85025, 80048, 84484) rendered by the OON
provider on July 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 19, 2021 to March 31, 2021.
You asked the Plan to pay for home health services. You say that your contract with the plan is a per visit contract. The Plan denied your request. The Plan says the rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the records do not show the services at issue were billed with a valid bill type. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 19, 2021 to March 31, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nail debridement services (11721) provided February 3, 2021.
You asked the Plan to waive the copayment for the nail debridement services. You say that you would like this cost share waived. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 podiatry services. You have been asked to pay a $30 copayment for the nail debridement services. These services falls 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 copayment for the nail debridement services (11721) provided February 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on March 10, 2021 by a Medicare opt out provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that the Plan reimbursed you last year for the same dental service. You also say that nothing has changed between this year and last year and you do not understand why you were reimbursed in 2020 but not 2021 for the same service. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective February 22, 2016, to February 22, 2022. The Plan also says that payment cannot be issued for services performed by a provider who has opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on March 10, 2021 by a Medicare opt out 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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient has a past medical history of epilepsy, coronary artery disease, and a stroke in April of 2021. You are living at home with ongoing weakness and falls despite home health physical
therapy. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.
You asked the Plan to pre-approve the SNF services. You say that you do not agree with the denial. The Plan denied your request. The Plan says the SNF services you are requesting do not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
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 SNF services. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmological services (CPT code
92004) provided on April 27, 2021.
You asked the Plan to waive the copayment for the ophthalmological services. You say that you thought you
would have a $0 copayment for a yearly eye examination. The Plan denied your request. The Plan says the
claim was processed accordingly with your 2021 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 shows that you received ophthalmological services on April 27, 2021. This was not a routine
eye exam. You were asked to pay a $40 copayment for the ophthalmological services. Your 2021 EOC states
that enrollees must pay a $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of
the eye, including an annual glaucoma screening for members at high risk. 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 ophthalmological services (CPT code 92004) provided on April 27, 2021.
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 you have bed sores and need proper care to get back
to baseline. The Plan denied your request. The Plan says under Medicare, the request is not medically
necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and
benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an extracorporeal photopheresis procedure (36522) provided on December 10, 2020.

You asked the Plan to pay for extracorporeal photopheresis. You say that that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the requested treatment is not a Medicare-covered benefit.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

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 extracorporeal photopheresis. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is not first line treatment.

The enrollee has not tried and failed first line treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of extracorporeal photopheresis have not been met. Therefore, we decided that the Plan does not have to pay for an extracorporeal photopheresis procedure (36522) provided on December 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided on April 6, 2021 by an out-of-network (OON) .
You asked the Plan to pay for the outpatient services provided by an OON provider. 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 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 services provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the PET services (CPT code(s): 78815 and A9552) provided to the enrollee on April 20, 2021, by an out-of-network provider.

You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 PET services (CPT code(s): 78815 and A9552) provided to the enrollee on April 20, 2021, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an endoscopy, ambulance transport and
inpatient stay (43248, R0206, A0425, A0429) provided from October 21, 2020, to October 28, 2020.

You asked the Plan to waive the copayments for the endoscopy, ambulance transport and inpatient stay. You
say that the charges were the result of an error during the surgical procedure and the copayments should be
waived. The Plan denied your request. The Plan says the correct cost sharing was applied for the services
rendered.

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 $175
copayment for outpatient surgical center services, a $200 copayment for ambulance transportation, and a $190
copayment per-day for days 1 through 4 of inpatient care.

We decided that the Plan does not have to waive the copayments for an endoscopy, ambulance transport and
inpatient stay (43248, R0206, A0425, A0429) provided from October 21, 2020, to October 28, 2020.
You asked the Plan to waive the copayments for the endoscopy, ambulance transport and inpatient stay. You
say that the charges were the result of an error during the surgical procedure and the copayments should be
waived. The Plan denied your request. The Plan says the correct cost sharing was applied for the services
rendered.

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 $175
copayment for outpatient surgical center services, a $200 copayment for ambulance transportation, and a $190
copayment per-day for days 1 through 4 of inpatient care.