Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device rental (E0675) and the segmental gradient pressure pneumatic appliance rentals (E0673 x 2) rendered by the out-of-network (OON) provider on May 10, 2021.
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items 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 items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device rental (E0675) and the segmental gradient pressure pneumatic appliance rentals (E0673 x 2) rendered by the out-of-network (OON) provider on May 10, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 15, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by 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 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 July 15, 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 subsequent nursing facility care (99309) provided on June 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that your physician provided medically necessary services in good faith. 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 subsequent nursing facility care (99309) provided on June 23, 2021 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies (99072) surgical trays (A4550), surgical supplies (A4694), durable medical equipment service (A9901) and infection control supplies (S8301) provided on February 5, 2021.
You asked the Plan to pay for the mobile anesthesia supplies. You say that you would like reconsideration
because these services were requested by the member's in-network physician. The Plan denied your request.
The Plan says the requested services are always bundled.
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 99072, S8301, A9901, A4649, and A4550 are not supported in the medical record.
Specifically, there is no separate reimbursement for these services. Payment for these services is included in the
payment for another service or procedure. Based on this information, we decided that Medicare rules for
coverage of the mobile anesthesia supplies have not been met. Therefore, we decided that the Plan does not
have to pay for the additional supplies (99072) surgical trays (A4550), surgical supplies (A4694), durable
medical equipment service (A9901) and infection control supplies (S8301) provided on February 5, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology services (J2001, 88307, 38500, J0690) provided on September 7, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for surgical pathology services. You say that other services were authorized. The Plan denied your request. The Plan says these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 surgical pathology services (J2001, 88307, 38500, J0690) provided on September 7, 2021, by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography, abdomen (74170) low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (Q9967) provided April 2, 2021.
You asked the Plan to waive the copayment for the imaging services. You say that you are requesting a reassessment and to get support for a copayment adjustment. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $150 copayment for advanced imaging services at a freestanding radiological facility. You have been asked to pay $150 copayment for the imaging services. The imaging services 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 computed tomography, abdomen (74170) low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (Q9967) provided April 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for speech therapy provided by a participating provider on July 13, 2021, and July 28, 2021.
You asked the Plan to waive the copayment for speech therapy. You say that you do not agree with these copayments. The Plan denied your request. The Plan says the correct copayments have been 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 $35 copayment for outpatient rehabilitation services/in-network/speech language therapy services. You have been asked to pay a $35 copayment for each speech therapy session. The total amount you are being asked to pay is $70 ($35 x 2 visits = $70). The correct copayment has been applied to the services that were
provided. Speech therapy falls within the outpatient rehabilitation services/in-network/speech language therapy services 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 speech therapy provided by a participating provider on July 13, 2021, and July 28, 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 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.
Your care needs can be met at a lower level of care. 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 a rollabout device.
You asked the Plan to pre-approve a rollabout device. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that canes (E0100, E0105) and crutches (E0110, E0111, E0112, E0113, E0114, E0116) are covered if specific criteria are met. 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 rollabout device. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no Local Coverage Determination defined coverage for a knee scooter/crutch substitute. There is no clinical literature showing a knee scooter/crutch substitute is safe and effective in the Medicare population compared to other standard ambulatory devices such as a cane, crutch or walker. 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 rollabout device have not been met. Therefore, we decided that the Plan does not have to pre-approve a rollabout device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81450) rendered by the out-of-network (OON) provider on February 9, 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 laboratory service (81450) rendered by the out-of-network (OON) provider on February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient behavioral health admission and services provided from July 30, 2021, to August 18, 2021.
You asked the Plan to waive the copayment for the inpatient behavioral health stay. You say that you are on a fixed income and cannot afford this copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment 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 $250 copayment for each of the first seven days of an inpatient mental health admission. There is a $1,750 maximum copayment per admission.
You have been asked to pay a $1,750 copayment for an inpatient mental health admission that lasted more than seven 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 inpatient behavioral health admission and services provided from July 30, 2021, to August 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for magnetic resonance imaging, brain (including brain stem) (70551) provided July 21, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that the facility is a freestanding building and is 10 miles from the hospital. You paid $75 which is what you were told at the time of service. You should not have to pay an additional amount. The Plan denied your request. The Plan says this service was processed with the correct copayment applied per the Evidence of Coverage.
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 $250 copayment for advanced imaging services in an outpatient hospital. You have been asked to pay $129.57 ($204.57 copayment - $75 paid) for the diagnostic service. Since the
allowed amount was less than the copayment amount, you are responsible for the lesser amount. The diagnostic
service 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 magnetic resonance imaging, brain (including brain stem)
(70551) provided July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the Immuno Bloodprint laboratory service provided on January 27, 2021.
You asked the Plan to pay for the Immuno Bloodprint laboratory service. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the Immuno Bloodprint laboratory service is not a covered service under the Plan's supplemental Wallet Benefit.
The Plan must follow Medicare rules. Medicare rules state that a supplemental benefit is an item or service not covered by original Medicare, that is primarily health related and for which the Medicare Advantage (MA) plan must incur a non-zero direct medical cost. We looked at the file, the Plan's contract and Medicare rules. Based on this information, we decided that the
Plan's supplemental Wallet Benefit rules have not been met. Specifically, the Immuno Bloodprint laboratory service is not covered under the Wallet Benefit offered by the Plan. Therefore, we decided that the Plan does not have to pay for the Immuno Bloodprint laboratory service provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for ophthalmic biometry (92136) provided on August 30, 2021.
You asked the Plan to pay for ophthalmic biometry. You say that this was billed correctly. The Plan denied your request. The Plan says that this required a modifier to indicate that only the professional component is being billed.
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 states that the service at issue required a modifier to indicate only the professional component is being billed, but the file shows that this service was billed with modifier -26 to indicate the professional component. The Plan has not provided information on why this modifier is not sufficient. The Plan also states that this was previously billed but has not provided a claim or other documentation to support this. Furthermore, the Plan has indicated that records were requested from and submitted by the provider, but no medical records were included in the case file. Therefore, we decided that the Plan has to pay for ophthalmic biometry (92136) provided on August 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic defibrillator rental (K0606) rendered by the out-of-network (OON) provider on June 9, 2021.
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the item 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 item at issue in this appeal. The Plan did not pre-approve the item at issue.
We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the automatic defibrillator rental (K0606) rendered by the out-of-network (OON) provider on June 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services rendered on September 17, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for in-network chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B.
Review of the file shows that you received chemotherapy on September 17, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the in-network chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B 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 chemotherapy services rendered on September 17, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation you require services on an inpatient basis, only in a skilled nursing facility setting. Overall there is inadequate documentation to certify a need for skilled nursing and therapy services in a skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 genicular radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the requested sacroiliac (SI) joint radiofrequency ablation is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation.