Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Favorable

 We decided that the Plan has to waive the copayment for an emergency room visit (99285) provided from May 14, 2021, to May 17, 2021.  You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered as you were admitted. The Plan denied your request. The Plan says that the cost-sharing 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. Your contract with the Plan says that enrollees must pay a $100 copayment for Emergency care.   The Plan says you must pay a $100 copayment for the emergency room visit unless you are immediately admitted. Based on the Plan contract, this copayment does not apply as the medical records provided indicated that you were admitted for observation. Therefore, we decided that the Plan has to waive the copayment for the emergency room visit (99285) provided from May 14, 2021, to May 17, 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: 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 does not have any medical needs or complex rehab issues that would require him to receive intensive, coordinated therapy services on an inpatient rehab 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 above. 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 a right above the knee amputation and has been discharged to home. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or 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 medical record documents a need for physical and occupational therapy, it does not document 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to provide coverage for additional physical therapy for the enrollee.  You asked the Plan to provide coverage for this service. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 provide coverage for this service.   Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient can transition to an independent home exercise program. The patient is also going for cervical surgery in January 2022 and her therapy needs can be re-evaluated postoperatively. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional physical therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital outpatient clinic visit (G0463) advance care planning (99497) provided on July 26, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient clinic visit. You say that resubmitting the claim with supporting documentation to support CPT code 99497 and G0438. Please review and reprocess for payment. 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 hospital outpatient clinic visit (G0463) advance care planning (99497) provided on July 26, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy including specimen collection (45378) provided on August 26, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a preventative screening and should 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. Medical records show you have a history of diverticulitis. Therefore, the colonoscopy in question is considered diagnostic and was billed 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 $400 copayment for surgery services performed in an outpatient hospital setting.   You have been asked to pay a $400 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy, billed with code 45378, is classified as a surgical procedure and was provided in an outpatient hospital setting. 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 diagnostic colonoscopy including specimen collection (45378) provided on August 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Epidural Steroid Injections (62323).

You asked the Plan to pre-approve the Epidural Steroid Injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says that coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Epidural Steroid Injections are covered when 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 Epidural Steroid Injections. Our reviewer says that the epidural steroid injections are medically necessary. Our physician reviewer found the documentation provided supports that the elements of Medicare coverage criteria have been met. 

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 Epidural Steroid Injections have been met. Therefore, we decided that the Plan has to pre-approve Epidural Steroid Injections (62323).

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 waive the copayment for a computed tomography (CT) scan of the leg provided on July 2, 2020.  You asked the Plan to waive the copayment for the CT scan. You say that you were not charged a copayment at the time of service. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 diagnostic and nuclear medicine radiological services, including CT scans.   You have been asked to pay a $225 copayment for the CT scan. CT scans fall 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 a computed tomography (CT) scan of the leg provided on July 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 2), pontic (D6245), and unspecified preventive service (D1999) provided on September 21, 2020.  You asked the Plan to pay for the dental services. You say that you were provided a treatment plan which showed you would be responsible for $2,097.48, and $902.92 would be paid by your insurance. You say that you received a bill for $902.92 that was not covered by your insurance. You also say that this should be paid. The Plan denied your request. The Plan says core build up is not listed as a covered service. The Plan says that retainer crowns are not listed as covered service. The Plan says that pontic is not listed as a covered service. The Plan also says unspecified preventive service is not listed as a covered service either.  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 dental services you received are not among those covered under this benefit. Additionally, the record shows that you confirmed with the Plan in December 2019 that you Dental Plan was ending and your new would begin, effective January 1, 2020. Therefore, we decided that the Plan does not have to pay for the core build up (D2950 x 2), retainer crowns (D6740 x 2), pontic (D6245), and unspecified preventive service (D1999) provided on September 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab and physician services provided on August 4, 2021 to August 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the out-of-network care. You say that these services were medically necessary and should be approved. The Plan denied your request. The Plan says out-of-network services are only covered in limited circumstances. The requested care was not urgent or emergent, was not referred by a network provider, and was not pre-approved by the Plan. These services could have been provided in-network.  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 lab and physician services provided on August 4, 2021 to August 9, 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 problem focused limited oral evaluation (D0140) provided on September 30, 2021.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was medically necessary. You also say that you have not found in-network providers who accept your coverage and would like to be covered out-of-network due to your medical complications. The Plan denied your request. The Plan says this service is not a covered expense 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 problem focused limited oral evaluation (D0140) provided on September 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the required services can be safely received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the doctor.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a telephone evaluation and management service (99443) provided on August 23, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a telephone evaluation and management service. You say that the Plan denied your request. The Plan says the services were not authorized by a network or primary care providers. The Plan also says that the referral was not authorized by attending physician. The Plan also says that they have also determined that these services were not urgent or emergent.  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 telephone evaluation and management service (99443) provided on August 23, 2021, by an out-of-network (OON) 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's ongoing skilled therapy and nursing needs can be provided 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 above. 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 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. 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: Drugs
Decision: Favorable

We decided that the Plan has to waive the coinsurance for a regadenoson injection (J2785) rendered on August 31, 2021.

You asked the Plan to waive the coinsurance for a regadenoson injection. You say that you did not receive the regadenoson injection and that it is a bogus charge. The Plan denied your request. The Plan says that you were charged the correct cost sharing amount.

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 failed to produce medical records or other forms of verification to verify the injection was given to the enrollee. Therefore, we decided that the Plan has to waive the coinsurance for a regadenoson injection (J2785) rendered on August 31, 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: 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 can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 rhabdomyolysis
after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient
admission. There are no complex nursing or 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 medical record documents a need for physical and occupational therapy, it does not
document 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.