Persius/hicric huggingface dataset:
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 service
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography (CTA) of the abdomen and pelvis (74174), the computed tomographic angiography (CTA) of the chest (71275), and the computed tomography (CT) scan of the lumbar spine (71275) provided on June 10, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 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 $225 copayment for in-network advanced imaging services, not including x-rays.
You have been asked to pay a $225 copayment for the in-network advanced imaging services provided. 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 computed tomographic angiography (CTA) of the abdomen and pelvis (74174), the computed tomographic angiography (CTA) of the chest (71275), and the computed tomography (CT) scan of the lumbar spine (71275) provided on June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says this item is statutorily not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for lancets (A4259), test strips (A4253), spring
powered device (A4258), and calibrator solution (A4256), provided on June 1, 2021.
You asked the Plan to waive the deductible for the diabetic supplies. You say that the cost share is wrong. The
Plan denied your request. The Plan says the provider is not a participating provider with the plan nor was your
deductible met.
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 20% coinsurance for out-of-network diabetic monitoring supplies
after the $75 deductible is met which applies to diabetes self-management training, diabetic services and
supplies.
The item or service you asked the Plan to waive the deductible for falls within the benefit category diabetes
self-management training, diabetic services and supplies. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a 20% coinsurance for out-of-network diabetic monitoring supplies after
the $75 deductible is met which applies to diabetes self-management training, diabetic services and supplies.
This cost sharing is a contractual obligation that had not been met at the time the diabetic supplies was received
on June 1, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lancets (A4259),
test strips (A4253), spring powered device (A4258), and calibrator solution (A4256), provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan does not have to pre-approve epidural steroid injections for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says there was no medical office note to support this request.
The Plan must follow Medicare rules. Medicare rules say that services are covered when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has chronic low back pain with radiation down the leg. He is taking medication,
has done a trial of physical therapy, and is doing a home exercise program. He has also tried heat and ice. A
prior epidural steroid injection produced 70% pain relief. The enrollee has a clearly documented progress note.
There is a clear indication for a repeat injection.
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 injection have been met. Therefore, we decided that the Plan does not have
to pre-approve epidural steroid injections for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
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 is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone graft (D6104), resorbable barrier (D4266), (surgical extraction D7210), and endosteal implant placement (D6010), provided on February 1, 2021.
You asked the Plan to pay for dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says these services are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone graft (D6104), resorbable barrier (D4266), (surgical extraction D7210), and endosteal implant placement (D6010), provided on February 1, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided from June 20, 2021, to June 23, 2021.
You asked the Plan to waive the copayment for emergency room visit. You say that you fell and were unable to stand or walk. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $90 copayment for emergency room visit. You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency Care 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 emergency room visit provided from June 20, 2021, to June 23, 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 this is medically necessary. The Plan denied your request. The Plan says care could be received in another 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for revision of left intercalary prosthesis with conversion to proximal femur placement. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $10 copayment for physician services.
You asked the Plan to waive this copayment. You say that you were told a wellness visit had no copayment. The Plan denied your request. The Plan says any services or additional diagnostics provided beyond the wellness visit limited services requires a copayment when billed by the provider.
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 $10 copayment for physician office visit. Your contract also states any additional services beyond the wellness visit will require a copayment. Your provider billed services beyond the wellness visit. 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 $10 copayment for physician services provided on June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on April 14, 2021.

You asked the Plan to pay for the testing services. You say that medical records were provided for review. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

The file shows that hereditary cancer panel testing was provided. The claim shows a place of service as an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Furthermore, if a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 13, 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 April 13, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective coating (V2750), vision supply (V2797), frames (V2020), and lens (V2784), provided on December 10, 2020.
You asked the Plan to pay for routine vision services. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating (V2750), vision supply (V2797), frames (V2020), and lens (V2784), provided on December 10, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve BRCA testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no family history of cancer in the breast, ovary, prostate, or pancreas.
The Plan must follow Medicare rules. Medicare rules say that BRCA testing is covered under specific 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 the testing. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer found according to the National Comprehensive Cancer Network, all patients with triple negative breast cancer should undergo genetic testing. In addition, the enrollee has at least two close family members that suspicion for a genetic mutation: colon and rectal cancer. Genetic testing is reasonable and medically 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 the testing have been met. Therefore, we decided that the Plan has to pre-approve BRCA testing.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy (43264), provided on May
13, 2021.
You asked the Plan to waive the copayment for the endoscopy. You say that the service should be covered. The
Plan denied your request. The Plan says the cost share 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 $250
per day for other outpatient procedures and services, including, but not limited to, diagnostic and therapeutic
endoscopy for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $250 per day for other outpatient procedures and services, including, but not
limited to, diagnostic and therapeutic endoscopy for the endoscopy. the endoscopy falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 endoscopy (43264), provided on May 13,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.
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 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 laboratory services are not supported in the medical record. Specifically, the documentation shows that an expanded pharmacogenomic panel was provided. If a laboratory procedure produces multiple reportable test results, only a single code shall be reported for the procedure. If there is no code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure code with a single unit of service. If no CPT code accurately describes the procedure performed, the laboratory may report code 81479 (Unlisted molecular pathology procedure) with one unit of service or may report multiple individual code describing the component test results when medically reasonable and necessary. Review of the file does not support that only one code was billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on February 25, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee was seen twice on the same day.
The Plan denied your request. The Plan says the documentation does not support an additional service.
The Plan must follow Medicare rules. Medicare rules say that or claim lines that have been determined to be
exact duplicates of another claim are denied.
We find that the CPT code 99285 was previously billed and paid for by the Plan. The denied claim does not
include indications to show there were multiple services provided on the same date. Based on this information,
we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided
that the Plan does not have to pay for the emergency room services provided on February 25, 2021.