Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided June 9, 2021.  You asked the Plan to pay for the psychotherapy services. You say that this appeal should be granted because the services provided were medically necessary. The Plan denied your request. The Plan says the services are not supported without the required documentation. There was no documented contact with the attending/primary care physician.  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.  We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy services (90834) provided June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray provided by on August 5, 2021.  You asked the Plan to waive the copayment for an x-ray. You say that the provider billed wrong and there should not be a copayment on a preventive service. The Plan denied your request. The Plan says the proper copayment was applied for this service.  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 $45 copayment for each Medicare-covered x-ray. The total amount billed was $42.48 which is less than the copayment amount of $45. Therefore, only a $42.48 copayment amount was billed.    You have been asked to pay a $42.48 copayment for an x-ray. An x-ray falls 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 an x-ray provided by on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950), pontic (D6241), and retainer crowns (D6751).  You asked the Plan to pre-approve the core buildup, pontic, and retainer crowns. You say that the enrollee will significantly benefit from the three-unit bridge. The Plan denied your request. The Plan says these services are not covered by the enrollee's dental 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. Therefore, we decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950), pontic (D6241), and retainer crowns (D6751).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive (92014) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided on October 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the medical vision services and imaging of optic nerve. You say that these services were medically necessary. The Plan denied your request. The Plan says these services are not covered because they were provided OON.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive (92014) and scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve (92133) provided on October 5, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on May 3, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that authorization should have been obtained by the facility prior to the provider's visit with this enrollee. You also say that the provider saw this enrollee in good faith and should be paid for their services provided. The Plan denied your request. The Plan says both the referring and attending providers are non-participating with the Plan. The Plan also says that no services were authorized by the Plan for either of these providers.  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. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on May 3, 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 assembly and operation of a heart/lung machine and autologous blood collection/processing by a perfusionist provided during a surgical procedure on August 25, 2021.  You asked the Plan to pay for the perfusionist services. You say that this is a necessary service to allow for surgery and should be covered/paid. The Plan denied your request. The Plan says this is not separately payable by Medicare.  The Plan must follow Medicare rules. Medicare rules say all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The rules also indicate that in order to bill Medicare and receive payment, a provider must be enrolled in the Medicare program.  Although these services may be appropriate, they are considered non-physician services, and payment for them is made to the hospital which must then furnish these services either directly or under arrangements. As such, separate Medicare payment cannot be made for the services at issue. Therefore, we decided that the Plan does not have to pay for assembly and operation of a heart/lung machine and autologous blood collection/processing by a perfusionist provided during a surgical procedure on August 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an X-ray of the foot (73620) and related services provided on July 7, 2021, by an out-of-network provider.  You asked the Plan to pay for an X-ray of the foot and related 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 out-of-network care have not been met.  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 an X-ray of the foot (73620) and related services provided on July 7, 2021, by an out-of-network 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 transfer to an IRF is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can receive the services you need in an alternate setting.  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 documentation provided, the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no acute or complex rehab nursing needs noted in the record. At your current functional level, you do not need intensive therapies consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. While you may benefit from physical and occupational therapies, your needs can safely be met in a less intensive setting. IRF admission is not medically necessary in this case.  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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors.  You asked the Plan to pre-approve an electronic connection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that an electronic connection between wheelchair controller and two ore more power seat system motors is only covered for certain indications.  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 an electronic connection. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the enrollee has four out of five upper extremity strength and full range of motion. The requested item exceeds the enrollee's medical need. The enrollee has two power options on the approved wheelchair, but the enrollee's upper extremity strength and function supports that the enrollee can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and two or more power seating system motors.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 3, 2021.  You asked the Plan to waive the copayment for a specialist visit. You say that you won the prior appeal and there was no communication that there would be a copayment for this service. The Plan denied your request. The Plan says the proper copayment was applied.  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 Specialty Care Physician.     You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within Physician/Practitioner services, including doctor's office visits 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 specialist visit provided on May 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 16, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for cataract surgery for the enrollee.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the plan is not under any contractual obligation to provide this surgery for an out-of-network provider.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.    The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for cataract surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a custom fabricated knee orthosis with an adjustable flexion and extension joint.  You asked the Plan to pre-approve a custom fabricated knee orthosis with an adjustable flexion and extension joint. You say that your doctor has confirmed that your knee is unstable. You say that you cannot walk without a brace and are unable to place weight on your leg because the knee goes out. You say that your doctor has advised that a standard brace would no longer work for you. You say that you are afraid that without this device you will fall again and become disabled. The Plan denied your request. The Plan says the requested orthosis is not considered medically reasonable or necessary in this case.  The Plan follows Medicare rules. Medicare rules say that custom orthotics are covered for certain medical indications.   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 a custom fabricated knee orthosis with an adjustable flexion and extension joint. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records from the enrollee's treating provider do not document a recent surgery or injury to the knee or instability of the knee joint on physical examination.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a custom fabricated knee orthosis with an adjustable flexion and extension joint have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated knee orthosis with an adjustable flexion and extension joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyeglasses provided on September 29, 2021.  You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the claim processed correctly and the Plan does not provide coverage for a refund.  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 the Plan has paid the correct amount for the eyeglasses and the Plan does not cover refunds. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on September 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the trimming of dystrophic nails (G0127) provided on September 1, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the trimming of dystrophic nails. You say that you did not know it would not be covered without prior authorization. The Plan denied your request. The Plan says the service was not urgent/emergent, the service is available with plan providers, and the service was with a non-contracted provider with no 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 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 trimming of dystrophic nails (G0127) provided on September 1, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete lower denture (D5120).  You asked the Plan to pre-approve a denture. You say that the enrollee needs this service. The Plan denied your request. The Plan says dental services to be received out of network are not covered.  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 denture is not among those covered under this benefit when provided out of network. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve prosthetic equipment.  You asked the Plan to pre-approve prosthetic equipment. You say that the requested equipment is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine coverage.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prosthetic equipment have not been met. Specifically, a detailed medical history of the enrollee's condition was not provided. Without this information, we cannot evaluate whether Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pre-approve prosthetic equipment.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on June 13, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.  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 the billed services are not supported in the medical record. Specifically, the documentation shows that the services were billed with secondary diagnosis code Z01.810. This diagnosis code should only be billed as a primary diagnosis. It is inappropriate to bill code Z01.810 as a secondary diagnosis.          Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on June 13, 2021.