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

We decided that the Plan does not have to pay for magnetic resonance imaging, any joint of lower extremity (73721) provided on December 23, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic services. You say that this is not an emergency service. Please review and determine if the enrollee will be responsible for the services provided The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for magnetic resonance imaging, any joint of lower extremity (73721) provided on December 23, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does 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 this enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $65 copayment charged for urgent care services provided on June 17, 2021.
You asked the Plan to waive this copayment. You say that you were unable to see your regular doctor due to staffing issues at the office. You say at urgent care they told you it would be $35. You do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on your Plan contract agreement.
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 $65 copayment for urgent care services. 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 $65 copayment charged for urgent care services provided on June 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 28, 2021.
You asked the Plan to pay for the services provided. You say that the services were provided in the family home. The Plan denied your request. The Plan says the claim was not billed with an appropriate place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99327 is Domiciliary or rest home visit for the evaluation and management of a new patient. We find that CPT code 99327 was billed with a place of service code 12, which indicates home. CPT code 99327 is used to report services to those residing in a facility with provides room, board, and other personal assistance services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the physician services provided on May 28, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (82803), bronchodilation evaluation
(94060), pulmonary function test (94727), diffusion capacity test (94729), and the exhaled nitrous oxide
measurement (95012) rendered by the out-of-network (OON) provider on August 31, 2020.

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 service (82803), bronchodilation evaluation (94060), pulmonary function test (94727), diffusion capacity test (94729), and the exhaled nitrous oxide measurement (95012) rendered by the out-of-network (OON) provider on August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87086, 87186, 87077, 81001) rendered by the out-of-network (OON) provider on May 19, 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 laboratory services (87086, 87186, 87077, 81001) rendered by the out-of-network (OON) provider on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on April 29, 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 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 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 (99213) rendered by the out-of-network (OON) provider on April 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the esophagogastroduodenoscopy (EGD) you had on February 25, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayment for the EGD. You say that you would not have had this procedure done if you had known there would be a copayment. You said this was done at the same time as your screening colonoscopy. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you were not charged a copayment for the colonoscopy, but the EGD is a separate surgical procedure for which a copayment applies.
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 $375 copayment for outpatient surgery at a hospital outpatient facility.
You have been asked to pay a $375 copayment for the upper GI endoscopy. The EGD falls within the outpatient surgery at a hospital outpatient facility 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 esophagogastroduodenoscopy (EGD) you had on February 25, 2021, at an outpatient hospital facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs close monitoring that can be provided in this type of facility. The Plan denied your request. The Plan says the requested admission to an LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services rendered by the OON
provider on February 17, 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 outpatient hospital services rendered by the OON provider on February 17,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the fundus photography with interpretation and report (92250) rendered by the out-of-network (OON) provider on July 30, 2020.
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 office visit (99214) and the fundus photography with interpretation and report (92250) rendered by the out-of-network (OON) provider on July 30, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve IMRT/IGRT 30 Gray (Gy) in 10 fractions.
You asked the Plan to pre-approve the IMRT/IGRT. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that guidelines do not support the use of IMRT for palliative lung cancer treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the IMRT/IGRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found IMRT/IGRT 30Gy in 10 fractions is being done for palliation for hemoptysis. This is a common treatment of symptomatic patients. 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 IMRT/IGRT have been met. Therefore, we decided that the Plan has to pre-approve IMRT/IGRT 30Gy in 10 fractions.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for advanced imaging provided on June 18, 2021.
You asked the Plan to waive this copayment. You say that you do not feel this copayment is appropriate for the service provided. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and the Plan contract agreement.
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 $250 copayment for advanced imaging in an outpatient hospital. You have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $250 copayment charged for advanced imaging provided on June 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist or physician other than the requesting dentist or physician (D9310) on April 15, 2021.
You asked the Plan to pay for the diagnostic consultation. You say that the dentist told you that you had to have this service, or they would not perform any other dental care for you. You also say this should be covered by your medical benefits. The Plan denied your request. The Plan says this service is not covered by your dental benefit, and these services are not medical in nature.
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. While this dental care may have been necessary due to issues resulting from a previous medical treatment, it was not provided as a necessary part of the medical treatment or in order for medical treatment to be provided. The care you need directly involves the care, treatment, filling, removal or replacement of teeth or structures directly supporting the teeth. Therefore, the service is dental in nature, and we decided that the Plan does not have to pay for the diagnostic consultation provided by a dentist or physician other than the requesting dentist or physician (D9310) on April 15, 2021.
Your complaint about potential misinformation and non-covered services provided by a Plan-contracted provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for hip surgery you had on May 18, 2021.

You asked the Plan to waive the coinsurance for the hip surgery. You say that you were kept in the hospital overnight, so this should be considered an inpatient stay. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for outpatient surgery. 

You have been asked to pay 20% coinsurance for the hip surgery. The records show that you were not formally admitted to the hospital for this procedure. Your Evidence of Coverage explicitly states that If you are having
surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an "outpatient." Because there was no formal order to admit you as an inpatient, the hip surgery falls within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for hip surgery you had on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam CT capture (D0364) provided on March 3, 2021.
You asked the Plan to pay for the limited oral evaluation (D0140) and cone beam CT capture (D0364). You say that you attended two appointments for a second opinion and was informed you wouldn't have to pay anything out-of-pocket. You say that it is unfair to be responsible for the bills after being assured they were taken care of. The Plan denied your request. The Plan says the limited oral evaluation is only allowed once per plan year and the cone beam CT capture is 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, you also have a maximum benefit of one limited oral evaluation per plan year. The Plan paid for the limited oral evaluation provided on February 17, 2021, which exhausted your benefit. The cone beam CT capture is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and cone beam CT capture (D0364) provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 4, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the 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 May 4, 2021.