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

We decided that the Plan does not have to waive the copayment for the electrocardiogram (93010) provided on September 13, 2021.
You asked the Plan to waive the copayment for the electrocardiogram. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says the copayment has processed 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 $5 copayment for outpatient diagnostic tests. You have been asked to pay a $5 copayment for the electrocardiogram. This service falls within the outpatient diagnostic test 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 electrocardiogram (93010) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the tetanus shot provided on December 14, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says that preventative immunizations and their administration is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that immunizations are covered when they are directly related to the treatment of an injury or direct exposure to a disease or condition.
We looked at the file and Medicare rules. The records show that the enrollee was experiencing cellulitis of the right finger due to a farming event while using a metal blade. Based on this information, we decided that Medicare rules for coverage of the services provided have been met. Therefore, we decided that the Plan has to pay for the tetanus shot provided on December 14, 2020.
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: 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 enrollee has infection to her knee and can barely move around. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with an ophthalmologist
(99211) provided on October 9, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was supposed to be for a
COVID-19 test prior to an upcoming surgery. You thought this would have a $0 copayment. The Plan denied
your request. The Plan says this claim was processed correctly, and your copayment was assessed in
accordance with your contract. An office visit with a specialist, such as an ophthalmologist, requires a $25
copayment.
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 an office visit with a specialist.
You have been asked to pay a $25 copayment for the office visit with a specialist. 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 office visit with an ophthalmologist (99211) provided on October 9, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve destruction of cutaneous vascular proliferative lesions.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that that laser treatment of your rosacea will not restore or improve
function and is considered cosmetic by Medicare.
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 these services. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. You have a covered
indication for destruction of cutaneous vascular proliferative lesions. V-beam treatment can be used when the
medical and topical treatments that did not provide complete resolution of lesions like in your case. Our
physician reviewer found that your condition meets criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to preapprove
destruction of cutaneous vascular proliferative lesions.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3D rendering.
You asked the Plan to pre-approve 3D rendering. 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 3D rendering. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case there is no reason given by the referring physician why such analysis would impact patient care/management.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D rendering have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D rendering.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the provision of test materials and equipment (G0249)
provided from June 26, 2020, to December 3, 2020, by out-of-network providers.
You asked the Plan to pay for the provision of test materials and equipment. You say that you did not know
these providers were not in-network. The Plan denied your request. The Plan says these services were not
provided through the Plan.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services,
plans are not required to make payments for any services received by enrollees that are not provided directly by
the Plan or through arrangements made by the Plan.
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not
have to pay for the provision of test materials and equipment (G0249) provided from June 26, 2020, to
December 3, 2020, by out-of-network providers
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (CPT code G0481) provided to the enrollee
on August 30, 2021, by an out-of-network provider.
You asked the Plan to pay for the out-of-network service. You say that the claim should be paid. The Plan
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider, and the services were not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0481) provided to the
enrollee on August 30, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee no longer requires the intensive therapy services provided at the acute rehabilitation unit.
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.
The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for to acute inpatient rehab after a hospitalization for cervical epidural abscess resulting in incomplete quadraplegia C5-C7. He was readmitted to acute care in December 2021 for diabetic ketoacidosis and urosepsis, then returned to the inpatient rehabilitation unit to complete his inpatient rehabilitation. His rehabilitation gains have plateaued. He is being treated for recurrent urinary tract infection. He requires ongoing hemodialysis. Medical problems are otherwise stable. There are no complex rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463), pathology services
(87507), and an influenza virus vaccination (90686, G0008) provided on October 14, 2021, by an OON
provider.
You asked the Plan to pay for a hospital outpatient clinic visit, pathology services, and an influenza virus
vaccination. You say that you regularly comply with all administrative requirements for payments. The Plan
denied your request. The Plan says this provider is not a network provider with the Plan and the services were
not referred by a network provider. The Plan also says that they have also determined that these services are not
urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for a hospital outpatient clinic visit (G0463),
pathology services (87507), and an influenza virus vaccination (90686, G0008) provided on October 14, 2021,
by an OON provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a prosthetic implant (L8683) provided on May 20, 2021.
You asked the Plan to waive the coinsurance for the prosthetic implant. You say that the services should be covered as you were not made aware of the cost-sharing beforehand. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Prosthetic devices and related supplies.
You have been asked to pay a 20% coinsurance for a prosthetic implant (the allowed amount is $5,041.23 x 20% $1,008.24). Prosthetic implants fall within the Prosthetic devices and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a prosthetic implant (L8683) provided on May 20, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (CPT code 97110-GP, CQ, KX (4 units)) provided to the enrollee on January 22, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this CPT code is not supported and there is a more appropriate healthcare common procedure coding system (HCPCS) code G0154 for the billed 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. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the service. Our reviewer found documentation submitted was reviewed and does not meet criteria. Documentation includes a therapy visit performed by a Physical Therapy Assistant on January 22, 2021. Services were performed in the home setting as the enrollee is homebound. Reporting a CPT code for services provided, would not be appropriate.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not
have to pay for the therapeutic procedure (CPT code 97110-GP, CQ, KX (4 units)) provided to the enrollee on
January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on June 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this was 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 throvider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) services provided on September 3, 2021.
You asked the Plan to waive the copayment for the MRI services. You say that you were never notified you would be charged a copayment. The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $225 copayment for advanced imaging services. You have been asked to pay a $216.67 copayment for the MRI services which is less than the required $225 copayment. These services fall within the advanced imaging 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 magnetic resonance imaging (MRI) services provided on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 12, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the laboratory tests are the responsibility of the dialysis center and are not separately reportable
by the laboratory.
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 denied codes are not supported in the medical record. Specifically, the records clearly show
that these laboratory services were related to the treatment of end-stage renal disease (ESRD).
Therefore, these services cannot be reported separately by the laboratory, and are the responsibility of the
dialysis center. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the
enrollee on July 12, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for debridement of nails (11721) provided July 15, 2021.  You asked the Plan to pay for debridement of nails. You say that you provided services in good faith. The Plan denied your request. The Plan says the services were not prior authorized.  The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan.  The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for debridement of nails (11721) provided July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services received on August 9, 2021.  You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your request. The Plan says the denial of acupuncture was appropriate given the clinical scenario.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, this was done for bilateral knee and ankle pain. Acupuncture is only covered for chronic low back pain. Additionally, acupuncture must be provided by a licensed physician practitioner. Licensed acupuncturists are not a covered provider type for this service. Therefore, we decided that the Plan does not have to pay for acupuncture services received on August 9, 2021.