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

 We decided that the Plan does not have to pay for an office visit (99214) provided August 5, 2021.  You asked the Plan to pay for the office visit. You say that the exam was required for auto insurance due to a previous accident. The Plan denied your request. The Plan says this type of exam is not covered.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file and Medicare rules. Physical examinations that are not medically necessary, such as those required by employment, insurance, licensing, marriage, and court-ordered examinations are non-covered. The record shows this exam was for insurance purposes. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive or reduce the copayment for an unna boot strapping procedure for wound care performed on June 1, 2021.  You asked the Plan to waive or reduce the copayment for the boot strapping procedure. You say that the enrollee's benefits indicate a $50 copayment for wound care. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $360 copayment for outpatient surgical procedures.   The enrollee has been asked to pay $211.70, which is less than the $360 copayment for the boot strapping procedure. Please note that this procedure is considered a surgical procedure. The boot strapping procedure falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive or reduce the copayment for an unna boot strapping procedure for wound care performed on June 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 7, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the clinical social worker will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on July 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for medical services received in the emergency room (ER) on August 25, 2021.
You asked the Plan to waive the copayment for the ER services. You say that the coding on this claim is very confusing, so this copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for emergency room services. You have been asked to pay a $90 copayment for the ER services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for medical services received in the emergency room (ER) on August 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care provided on June 1, 2021, through June 13, 2021.
You asked the Plan to waive the copayment for the SNF care. 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 $184 copayment per day 21-100 for skilled nursing facility (SNF) care. You have been asked to pay a $184 copayment per day 21-100 for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. Our records indicate you were in a skilled nursing facility for 31 days. The first 20 days were covered, and you were asked to pay a $184 copayment for the remaining 11 days. 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 skilled nursing facility (SNF) care provided on June 1, 2021, through June 13, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve magnetic resonance images (MRIs).  You asked the Plan to pre-approve MRIs. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for these tests is correct.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.   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 MRIs. Our reviewer says that the enrollee meets the Medicare criteria for the requested MRIs. Our physician reviewer found MRI is useful in examining the head, central nervous system, and spine, disc, disc disease, and without regard to whether radiological imaging has been tried first to diagnose the problem. MRI is capable of demonstrating a wide variety of soft-tissue lesions with contrast resolution equal or superior to CT scanning in various parts of the body. The documentation indicates the patient has persistent symptoms despite conservative treatment of therapy. There is a positive Spurling sign on physical exam suggestive of a cervical radiculitis. This particular patient has a history of melanoma. Melanoma can cause metastatic vertebral and intramedullary spinal cord metastatic melanoma and for this reason it is prudent to obtain a cervical MRI as this modality would allow for soft tissue lesion imaging.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRIs have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance images (MRIs).   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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (G0299) provided to the enrollee from May 11, 2021 to May 14, 2021.
You asked the Plan to pay for home health services. You say that the services were medically necessary and properly billed. The Plan denied your request. The Plan says the claim was not billed on the proper form and cannot be paid.
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 claim was not filed on a UB-04 or 837I form. The plan requested a correct claim and none was received. Therefore, we decided that the Plan does not have to pay for the home health services (G0299) provided to the enrollee from May 11, 2021 to May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiac genetic panel testing provided on June 8, 2021.
You asked the Plan to pay for genetic testing. You say that this was medically necessary to treat the enrollee. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the ordering provider denies any relationship with the enrollee.
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, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiac genetic panel testing provided on June 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services rendered from June 26, 2021 to June 30, 2021.
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 that the services are not covered.
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. The Plan has not provided a clear denial reason for these services. There is no documentation or Medicare rules provided to support that the services are not covered, per Medicare rules. Therefore, we decided that the Plan has to pay for the inpatient hospital services rendered from June 26, 2021 to June 30, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Erleada tablets.  You asked the Plan to pre-approve self-administered drug. You say that the enrollee has tried and failed other drugs and has no other viable treatment options. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Erleada tablets.   Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the nuclear medicine study (78452) and
regadenoson injection (J2785) provided on January 18, 2021.
You asked the Plan to waive the cost-share for the nuclear study and drug injection. You say that you were not
aware that you would have a copayment for these services and were not consulted regarding your share of the
cost prior to services. The Plan denied your request. The Plan says this claim was processed correctly, and your
cost-share was assessed in accordance with your contract.
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 $100
copayment for Medicare-covered nuclear medicine and 20% coinsurance for Part B medications and contrast
agents injected during the service.
You have been asked to pay a $100 copayment for the nuclear study, which falls within the Medicare-covered
nuclear medicine benefit category. You have also been asked to pay $38 for the regadenoson injection, which is
a Part B medication and/or contrast agent injected during the service. The Plan's allowed amount for this
injection service is $189.98 ($189.98 x 20% = $38). This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for
the nuclear medicine study (78452) and regadenoson injection (J2785) provided on January 18, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided April 2, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed 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. We find that CPT codes 87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, & 87798 are not supported in the medical record. Specifically, the place of service listed on the claim form (81, Laboratory) does not match the place of service detailed in the records (13, Assisted Living Facility). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, 87798) provided April 2, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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 shingles vaccine provided August 16, 2021.
You asked the Plan to pay for the shingles vaccine. You say that you were not aware this would not be covered under the Plan's medical benefit. The Plan denied your request. The Plan says this vaccine does not meet Medicare Part B coverage rules.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided August 16, 2021.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, cervical (72040) radiologic examination, spine, lumbosacral (72100) provided July 14, 2021.
You asked the Plan to pay for the chiropractic service. You say that you were told by Plan representatives that the denied services were covered by the Plan. You were told to resubmit and it was denied again. You would like to be reimbursed for the out-of-pocket payment of $142.00. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) radiologic examination, spine, cervical (72040) radiologic examination, spine, lumbosacral (72100) provided July 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from May 21, 2021, to June 5, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were dissatisfied with the care the enrollee received during their stay, and you were told by an employee that there would be no cost to you for these services. The Plan denied your request. The Plan says they found evidence that you were previously quoted a copayment amount of $1,871 in error. After review, the copayment has been adjusted to $1,871 because this quote was provided by the Plan and is less than the required $2,100 copayment for inpatient hospital care.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for each of the first seven days of an inpatient hospital stay. There is a $0 copayment for additional days.
The enrollee has been asked to pay a $1,871 copayment for the inpatient stay which exceeded seven days. An inpatient stay of seven days or more would usually require a $2,100 copayment ($300 x 7 = $2,100), but the Plan has processed this claim with a lesser amount due to a previous error. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from May 21, 2021, to June 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and panoramic x-ray.
You asked the Plan to pre-approve the office visit and panoramic x-ray. You say that your dental issues are due to a medical condition and not a regular dental issue. The Plan denied your request. The Plan says this appeal is for post-radiation dental care which is not a covered benefit per 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. Your dental benefit only covers preventive exams and cleanings, and this exam for treatment planning would not fall into that category.
Therefore, we decided that the Plan does not have to pre-approve an office visit and panoramic x-ray
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on June 28, 2021.
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 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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit rendered on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on June 26, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you had open heart surgery. You also say that you have never been in a hospital that allowed a person to bring in their own medicine. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on June 26, 2021.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.