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

We decided that the Plan does not have to pay for computed tomography, abdomen and pelvis (74177) provided March 11, 2021.
You asked the Plan to pay for the diagnostic service. You say that please review attached documents that support reconsideration of this procedure denial. The Plan denied your request. The Plan says payment for this service is included in the payment to the facility
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, payment for this service was included under the facility payment. Payment for this service is the responsibility of the facility or hospital. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography, abdomen and pelvis (74177) provided March 11, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the specialist office visit provided on April 13, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you did not have an
office visit. You say only went to get your devices checked. The Plan denied your request. The Plan says that
you have been asked to pay the correct cost-sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. According to our records, the Plan did not send the correct Evidence of
Coverage, this means we cannot determine if the cost sharing amount you are being asked to pay is correct.
Therefore, we decided that the Plan has to waive the copayment for the specialist office visit provided on April
13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on May 1, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on May 1, 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 services provided by an out-of-network provider on March 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 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 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the guided tissue regeneration - resorbable barrier, per
site (D4266), surgical placement of implant body: endosteal implant (D6010), bone graft at time of implant
placement (D6104), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated (D7210), deep sedation/general anesthesia - first 15
minutes (D9222), deep sedation/general anesthesia - each subsequent 15 minute increment (D9223), and
therapeutic parenteral drug, single administration (D9610).
You asked the Plan to pre-approve guided tissue regeneration, endosteal implant, bone graft associated with
implant placement, tooth extractions, general anesthesia and therapeutic parenteral drugs. You say that you
would like the services covered. The Plan denied your request. The Plan says the request exceeds your
maximum of $1,000 for supplemental dental services. Additionally, implants and implant related dental
services are not covered under your benefits.
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 covers certain dental
services up to a maximum of $1,000.
We looked at the file and Medicare rules. Implants and any related services and supplies associated with the
placement and care of implants are not covered under your benefits. Additionally, the Plan does not cover
dental services over a maximum amount of $1,000 per benefit period. Therefore, we decided that the Plan does
not have to pre-approve the guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement
of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), extraction,
erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal
flap if indicated (D7210), deep sedation/general anesthesia - first 15 minutes (D9222), deep sedation/general
anesthesia - each subsequent 15 minute increment (D9223), and therapeutic parenteral drug, single
administration (D9610).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room visit and dental services provided on February 12, 2021.
You asked the Plan to pay for the emergency room visit and dental services. You say that the enrollee was unable to make an appointment with a dentist. The Plan denied your request. The Plan says the services provided are not a covered 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.
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 pay for the emergency room visit and dental services provided on February 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2020 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on July 10, 2020 by a non-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral exam (D0150), endodontic procedure (D3999), pulpal debridement (D3221), incomplete endodontic therapy (D3332), and preventative procedure (D1999), provided on May 13, 2021.
You asked the Plan to pay for the routine dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exhausted your Plan benefit for a comprehensive oral exam and the other requested services are not covered under your benefit Plan.
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 among those covered under this benefit. Specifically, you have exhausted your Plan benefit for a comprehensive oral exam and the other requested services are not covered under your benefit Plan.
Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam (D0150), endodontic procedure (D3999), pulpal debridement (D3221), incomplete endodontic therapy (D3332), and preventative procedure (D1999), provided on May 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on February 10, 2021.

You asked the Plan to pay for psychotherapy (90834). You say that your physician provided medically necessary services to the member in good faith. The Plan denied your request. The Plan says there was no documented contact with the attending /primary care physician.

The Plan must follow Medicare rules. Medicare rules say that that there must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record. 

We looked at the file and Medicare rules. There is no documentation of consent/declination or consultation with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare rules for coverage of psychotherapy (90834) have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services, provided on March 25, 2021, through March 27, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was 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 $275 copayment for each day one through six for inpatient hospital care. You have been asked to pay a $275 copayment for each day one through six for the inpatient hospital services. This service falls within the inpatient hospital 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 inpatient hospital services, provided on March 25, 2021, through March 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on March 23, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says then enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 physician services provided to the enrollee on March 23, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy with biopsy and magnetic resonance imaging (MRI) provided on May 4, 2021 and May 6, 2021.
You asked the Plan to waive the copayments for colonoscopy and MRI. You say that it seems that under this plan there is no point in having Medicare Part B. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $225 copayment for colonoscopy with biopsy provided at an ambulatory surgical center and $175 copayment for MRI. Your total copayment responsibility is therefore $400. You have been asked to pay $225 copayment for colonoscopy and $175 copayment for MRI. Colonoscopy and MRI fall within the "Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" and "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit categories. 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 a colonoscopy with biopsy and magnetic resonance imaging (MRI) provided on May 4, 2021 and May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) interpretation and report rendered on April 26, 2021.

You asked the Plan to waive the copayment for these services. You say that your doctor explained the EKG was a routine procedure and you would like the Plan to not process a copayment. The Plan denied your request. The Plan says the copayment was 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 $30 copayment for Medicare-covered non-radiological diagnostic services.

Review of the file shows that you had an EKG on April 26, 2021. Per the contract with the Plan, there is a $30 copayment for Medicare-covered non-radiological diagnostic services. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services is $18.33. Given that the allowed amount was less than the $30 copayment, you have been asked to pay $18.33 for these services.

Therefore, we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) interpretation and report rendered on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on June 15, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that you would like the Plan to pay for this therapist as you cannot pay. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 15, 2021 by an out-of-network provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 11, 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 November 11, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

Explanation of decision
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 IRF care is medically necessary for the enrollee's condition. 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 based on the medical records the enrollee is medically stable with debility. There is no other medical complexity, to require physical medicine and rehabilitation physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions.
In addition, the enrollee has no documented rehab nursing needs. The documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on lack of medical complexity and skilled rehab nursing or therapy participation. The enrollee's therapy needs can be addressed at a lower intensity and alternate 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 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 services provided to you on April 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided to you on April 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 50-trip limit.

You asked the Plan to pre-approve the additional trips for routine transportation. You say that you need to go to several appointments weekly and would like additional trips approved. The Plan denied your request. The Plan says additional trips beyond the trip limit are not covered.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 50 trips per year.

We looked at your request, the records in the case file, and the rules. The Plan provided documentation showing that at the time of their review you had used 46 transportation trips from your transportation benefit. Once the benefit is exhausted, you are not covered for additional trips. Therefore, we decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 50-trip limit.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), provided on March 30, 2021.
You asked the Plan to pre-approve a limited oral evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says you received the service from 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 among those covered under this benefit. Specifically, you received the service from a provider who has opted-out of Medicare. Therefore, we decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), provided on March 30, 2021.