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

 We decided that the Plan does not have to pay for the anesthesia for procedures on nerves, muscles, tendons, and fascia of the lower leg, ankle, and foot (01470) rendered by the out-of-network (OON) provider on July 20, 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 anesthesia for procedures on nerves, muscles, tendons, and fascia of the lower leg, ankle, and foot (01470) rendered by the out-of-network (OON) provider on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87641, 87798, 88305, 88312) provided on October 27, 2020.  You asked the Plan to pay for laboratory services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with the correct place of service.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87641, 87798, 88305, 88312) provided on October 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).

You asked the Plan to pre-approve TMS. You say that TMS is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about your condition you do not meet the requirement. Your current TMS treatment has not resulted in a 50 % improvement supported by a depression rating scale score.

The Plan follows Medicare rules. Medicare rules say that TMS retreatment may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% improvement in standard rating scale measurements for depressive symptoms.

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 TMS. Our reviewer says that TMS is not medically necessary. Our physician reviewer found that based on review the medical records provided and utilizing the Medicare LCD (L34998) for repetitive transcranial magnetic stimulation that specifically requires the improvement of 50% as shown in the standard rating scale for depression, which is shown through the documentation. Utilizing the information from the documentation provided it is difficult to see how the additional requested 10 sessions would improve per documented PHQ 9 is improved. Based on the records provided, you do not meet the criteria for TMS therapy as TMS is not considered reasonable or medically necessary for you as you suffer from Major Depressive Disorder and you have shown a 50% improvement based on the standard rating scale including the PHQ9 as documented above. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TMS have not been met. Therefore, we decided that the Plan does not have to pre-approve TMS.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided June 18, 2021.  You asked the Plan to waive the copayment for the ambulance services and ground mileage. You say that if you had known there would be a copayment, you would have used other transportation. The Plan denied your request. The Plan says the copayment 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 $325 copayment per trip for Medicare-covered ambulance services.   You have been asked to pay a $325 copayment for the ambulance services and ground mileage. The ambulance services and ground mileage fall within the Ambulance 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 the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided June 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for pulmonary rehabilitation provided on June 21, 2021, and June 28, 2021.  You asked the Plan to waive the copayment for pulmonary rehabilitation. You say that you have never paid a copayment for this service and think this is being billed incorrectly. The Plan denied your request. The Plan says the copayments 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 $15 copayment for Medicare-covered pulmonary rehabilitation services from a network provider.    You have been asked to pay a $15 copayment for each pulmonary rehabilitation visit. The total amount you owe is $30 ($15/visit x 2 visits = $30). Pulmonary rehabilitation falls within the "Pulmonary rehabilitation 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 pulmonary rehabilitation provided on June 21, 2021, and June 28, 2021.
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 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 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary as there would be no clinical advantage. Transfer to a lower level of care may be considered.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received on March 11, 2021.  You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were misinformed about this cost sharing and you cannot afford this. 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 chemotherapy drugs.   You have been asked to pay 20% coinsurance for the chemotherapy drugs. 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 chemotherapy drugs you received on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for office visits provided on February 3, 2021, and August 17, 2021.  You asked the Plan to waive the deductible for the office visits. You say that you do not think a provider can bill for an office visit and surgical procedure on the same day according to Medicare rules. You state that if that is correct, the Plan should have denied the two claims. The Plan denied your request. The Plan says the claims were processed correctly toward your deductible. The Plan states a review of the medical records indicates you had a specialist visit for a 6-month skin check where the provider treated you with cryotherapy (the use of extreme cold to freeze and remove abnormal tissue). The specialist office visit was billed as an office visit in addition to a same-day procedure by the same provider.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $9,000 yearly deductible which applies to Physician/Practitioner Services, including doctor's office visits.   The office visits you asked the Plan to waive the deductible for fall within the Physician/Practitioner Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $9,000 yearly deductible which applies to Physician/Practitioner Services, including doctor's office visits. You have been asked to pay $268.95 toward your deductible for the two claims.  This cost sharing is a contractual obligation that had not been met at the time the office visits were received on February 3, 2021, and August 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible for office visits provided on February 3, 2021, and August 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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 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 a percutaneous peripheral nerve stimulator.  You asked the Plan to pre-approve a percutaneous peripheral nerve stimulator. 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. 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 a percutaneous peripheral nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is device is considered experimental/investigational for diabetic peripheral neuropathy. Therefore, the request is deemed 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 a percutaneous peripheral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous peripheral nerve stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for therapeutic injection services you received at an outpatient hospital facility from April 21, 2021, to June 16, 2021.  You asked the Plan to waive the copayments for the therapeutic injection services. You say that you switched from an infusion drug to an injection drug.  You do not believe you should have to pay a copayment for these injections, as it should be considered part of your chemotherapy treatment. The Plan denied your request. The Plan says you were charged these copayments 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 $50 copayment for surgery or other services at a hospital outpatient facility.   You have been asked to pay a $50 copayment for the therapeutic injection services. The therapeutic injection services fall within the surgery or other services 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 copayments for therapeutic injection services you received at an outpatient hospital facility from April 21, 2021, to June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on June 10, 2021.

You asked the Plan to pay for the consultation. You say that you could not wait to have this service provided. The Plan denied your request. The Plan says this service is not a covered benefit under your 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 pay for the consultation (D9310) provided on June 10, 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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 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 pay for the chiropractic manipulative treatment (98941) provided on April 7, 2021 to May 20, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the chiropractic services. You say that you had paid up front for these services and was expecting reimbursement. 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 the chiropractic manipulative treatment (98941) provided on April 7, 2021 to May 20, 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 the x-ray you had at a radiologist's office on June 8, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that you had this x-ray done in your primary care doctor's office, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for basic radiology services in a specialist's office. 

We investigated the facility where these services were rendered. This medical group's office building houses primary and specialty care offices. The specific office within the building where you received the x-ray is a radiology office, which is a specialty office. The radiologist, not your primary care provider, performed this x-ray service. 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 x-ray you had at a radiologist's office on June 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a physical therapy evaluation provided by a participating provider on June 30, 2021.  You asked the Plan to waive the copayment for a physical therapy evaluation. You say that you did not receive and care or given any solutions from the physical therapy evaluation. The Plan denied your request. The Plan says the correct copayment has 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 $40 copayment for outpatient rehabilitation services.   You have been asked to pay a $40 copayment for a physical therapy evaluation. The correct copayment has been applied to the services that were provided. A physical therapy evaluation falls within the outpatient rehabilitation 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 a physical therapy evaluation provided by a participating provider on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft in conjunction with periradicular surgery - per tooth, single site (D3428) and removal of residual tooth roots (cutting procedure) (D7250) provided June 23, 2021.

You asked the Plan to pay for the bone graft in conjunction with periradicular surgery and removal of residual tooth roots. You say that you paid out of pocket for the services and would like reimbursement. The Plan denied your request. The Plan says there is no coverage under your benefits for the requested services.

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 pay for the bone graft in conjunction with periradicular surgery - per tooth, single site (D3428) and removal of residual tooth roots (cutting procedure) (D7250) provided June 23, 2021.