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

 We decided that the Plan does not have to pay for the laboratory services rendered on July 1, 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 testing is not covered.  The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary.  We looked at the file and Medicare rules. The services are billed under code 81455. 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 pay for the laboratory services rendered on July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided from May 4, 2021, to May 10, 2021.  You asked the Plan to waive the copayment for outpatient hospital observation. You say that you were admitted to the hospital and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for outpatient hospital observation.   The medical records show that you received outpatient hospital observation from May 4, 2021, to May 10, 2021. Therefore, you are responsible to pay the $50 copayment.   You have been asked to pay a $50 copayment for outpatient hospital observation. Outpatient hospital observation falls within the outpatient hospital observation 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 outpatient hospital observation provided from May 4, 2021, to May 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) provided May 28, 2021 to June 15, 2021.  You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF services. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage.  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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 pay for the skilled nursing facility (SNF) provided May 28, 2021 to June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a mental health office visit (99213) provided on September 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a mental health office visit. You say that you have had many visits with this provider and never needed a pre-authorization before. You also say you do not understand why you need an authorization now and that this visit has been denied. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are 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 a mental health office visit (99213) provided on September 27, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for air ambulance services provided on May 4, 2021.  You asked the Plan to pay for air ambulance services. You say that this was an emergent request and response of the aircraft to transport a patient that was potentially having a stroke to the closest appropriate facility with a comprehensive stroke center.  Air ambulance was requested by responding ground EMS unit to expedite travel to a comprehensive stroke center. The Plan denied your request. The Plan says air ambulance transport was not medically necessary.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 air ambulance services. Our reviewer says that the air ambulance was not medically necessary. Our physician reviewer found that the enrollee was a then, 74-year-old female. The provider was dispatched to Jennings airport for rendezvous with MedExpress for transport due to possible Cerebrovascular accident (CVA). The enrollee's family told providers that the enrollee was found in bed that morning "not acting right".  According to family the enrollee had slurred speech and facial droop that was new, she also had a prior CVA. The ambulance did not submit a claim for ground transport provided. On May 4, 2021, the air ambulance transported the enrollee from Jennings airport to the Medical Center per enrollee's request. The enrollee was inappropriately transported by air ambulance to a more distant facility. Jennings American Legion Hospital was the nearest appropriate facility with the capabilities to treat the enrollee. The review has determined that the documentation did support that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 3, 2021.  You asked the Plan to pay for the lab services. You say that the lab serves those undergoing life-sustaining dialysis treatment. The Plan denied your request. The Plan says the labs are not separately reportable.  The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shower chair provided on August 19, 2021.  You asked the Plan to pay for the shower chair. You say that you were recommended a shower chair. The Plan denied your request. The Plan says that this is not covered by the Plan.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for the shower chair provided on August 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a vision exam provided on  August 24, 2021.  You asked the Plan to waive the copayment for a vision exam. The Plan denied your request. The Plan says the claim processed correctly with a $40 specialist copay, and no coverage for the refraction.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Vision Care, Medicare-covered vision care. Your contract with the Plan also says that Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts.  You have been asked to pay a $40 copayment for a vision exam. A vision exam falls within the Vision Care, Medicare-covered vision 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.  Additionally, Original Medicare doesn't cover routine eye exams (eye refractions) for eyeglasses/contacts. Therefore, we decided that the Plan does not have to waive the copayment for a vision exam provided on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and surgical extraction (D7210) provided on July 9, 2021, and August 3, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and surgical extraction. You say that you have up to $1,000 of dental benefits and your primary dentist referred you to an oral surgeon. You also say that none of the dentists in your area participate in Medicare. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective October 25, 2016, to October 25, 2022.  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 provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and surgical extraction (D7210) provided on July 9, 2021, and August 3, 2021 by a Medicare opt out provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support an interspinous spacer device as a safe and effective alternative to the gold standard of surgical decompression.  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 pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the colorectal cancer screening received on August 26, 2021.  You asked the Plan to pay for the colorectal cancer screening. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received exceed your benefit limit.  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.  While the test received is covered by the Plan, it is only covered once every 12 months. Review of the file shows that you received this screening on August 26, 2021. You previously received this screening on September 15, 2020. This means 12 months had not passed since your previously received these services. Therefore, we decided that the Plan does not have to pay for the colorectal cancer screening received on August 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the life vest provided from August 18, 2020, to November 17, 2020.  You asked the Plan to waive the coinsurance for the life vest. You say that the services should be covered as you were not made aware of the costs beforehand. The Plan denied your request. The Plan says the coinsurance applied correctly based on the item provided.  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 20% coinsurance for Durable Medical Equipment (DME) and related supplies.     You have been asked to pay a 20% coinsurance for a three-month rental of a life vest (the total allowed amount is $8698.5 x 20% = $1,730.7). Life vests fall within the Durable Medical Equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the life vest provided from August 18, 2020, to November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve group therapy (yoga).  You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says group therapy at this level of service is not appropriate nor in line with medical standards.  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 pre-approve the therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the request for yoga is a medical necessity for your diagnoses or to improve your functional level. The request exceeds your medical needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve group therapy (yoga).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on April 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. 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 records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on April 22, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on  October 5, 2021.  You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the claim processed correctly applying $200 under the member's eye glass benefit and left $100 toward the member's responsibility.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the claim processed correctly applying $200 under your eye glass benefit and left $100 toward your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an eye refraction provided on July 20, 2021.  You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says an eye refraction is only covered by in-network providers.  Medicare generally does not cover routine vision services. However, the Plan offers a routine benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The file shows that the eye refraction was not provided by the Plan's vision care provider. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for electrical stimulation (G0283) mechanical traction (97012) provided on June 2, 2021.  You asked the Plan to pay for the chiropractic services. You say that per Medicare guidelines, the services with a GA modifier should deny PR and not CO. 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 electrical stimulation (G0283) mechanical traction (97012) provided on June 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a mammography (77066) and an ultrasound of the breast (76642, G0279) provided on July 26, 2021.  You asked the Plan to waive the copayment for the mammography and ultrasound of the breast. You say that you don't understand why you have 2 charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $170 copayment for Outpatient diagnostic tests and therapeutic services and supplies.    You have been asked to pay a $170 copayment for a mammography and ultrasound of the breast. Mammograms and ultrasounds fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a mammography (77066) and an ultrasound of the breast (76642, G0279) provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) provided on August 3, 2021.  You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as they are a part of your annual wellness visit. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $5 copayment for Physician/Practitioner services, Including Doctor's Office Visits.    You have been asked to pay a $5 copayment for the office visit. The record indicates that you received additional lab work during this visit which is what prompted the copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit (99213) provided on August 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453) provided on May 13, 2021.  You asked the Plan to pay for neurophysiology monitoring services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier.  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, we have confirmed that code G0453 is a column II code to column I code 95887. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453) provided on May 13, 2021.