Persius/hicric huggingface dataset:
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 the medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an additional anterior segment aqueous drainage device.
You asked the Plan to pre-approve insertion of an additional anterior segment aqueous drainage device. 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 follows Medicare rules. Medicare rules say that insertion of glaucoma drainage device(s) into the subconjunctival space are limited to one insertion per eye per day when the medically reasonable and necessary criteria as stated above are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve insertion of an additional anterior segment aqueous drainage device. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the record indicates that you have been approved for cataract surgery and stent placement. Coverage of an additional stent is considered not medically reasonable and necessary and precluded from coverage under the local coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of an additional anterior segment aqueous drainage device have not
been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an additional anterior segment aqueous drainage device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on August 11, 2021, billed with several codes including 77049.
You asked the Plan to pay for the outpatient hospital services as billed. You say that this should be paid as medically necessary. The Plan denied your request. The Plan says this was billed with an invalid code which caused the claim to deny.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that OPPS claims are subject to the I/OCE which applies edits to outpatient hospital claims. Code 77049 has a status indicator of "B" in the OPPS. This means that it is not recognized by OPPS. This triggered OCE edit 62, which requires the claim to be returned to provider. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on August 11, 2021, billed with several codes including 77049.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve branch destruction by neurolytic agent provided on June 30, 2021.
You asked the Plan to waive the copayment for the nerve branch destruction by neurolytic agent. You say that the procedure didn't work, and you can't afford to pay the copayment. You say that you are appealing for insurance to pay. The Plan denied your request. The Plan says the copayment 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 $300 copayment for all other Ambulatory Surgical Center (ASC) services.
You have been asked to pay a $300 copayment for the nerve branch destruction by neurolytic agent. The nerve branch destruction 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 nerve branch destruction by neurolytic agent provided on June 30, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the extremity vein duplex scan provided
on March 25, 2021, billed with code 93970-26-XS.
You asked the Plan to pay for the duplex scan interpretation. You say that the records support the billed
services on the claim. The Plan denied your request. The Plan says only one unit of this code is supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 93970-26-XS is Duplex scan of extremity veins including
responses to compression and other maneuvers; complete bilateral study.
We find that CPT code 93970-26-XS is not supported in the medical record. Specifically, one bilateral study of
the upper extremities was documented in the record, which was paid on appeal.
There is no evidence that a second study was performed to justify the billing of the second unit with modifier -XS. Based on this information, we decided that Medicare rules for coverage of the duplex scan interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the extremity vein duplex scan provided on March 25, 2021, billed with code 93970-26-XS.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, scrotum and contents (76870) provided May 12, 2021.
You asked the Plan to waive the copayment for the diagnostic service. You say that you only have social security as your source of income so please consider this appeal. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $175 copay for each Medicare covered outpatient diagnostic procedure and test in an outpatient facility. You have been asked to pay $120.71 copay for the diagnostic service. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. the diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound, scrotum and contents (76870) provided May 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on September 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the re-cement or re-bond crown. You say that you went to an OON provider because you did not want to wait until October to have your crown fixed. You also say that the Plan representatives did not advise that you would be responsible for payment for going OON even if it were for an emergency. The Plan denied your request. The Plan says services are not covered when rendered by an OON provider. The Plan also says that you did not contact the Plan prior to the services being rendered to verify the provider's network status, nor to obtain a list of in-network providers.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on September 7, 2021 by an out-of-network (OON) provider.
Your complaint about the Plan representatives not providing you with all of the information you needed is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 requested LTACH admission is
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not
medically necessary.
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 admission is not medically necessary. Our physician reviewer found the enrollee
appears to be gradually improving and should only require additional short-term acute care services for
additional infection treatment and vent weaning that can be safely completed at the current facility. The
enrollee does not require services at the LTACH that are not already available at the current facility. 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 it would not be clinically
advantageous.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued referral with an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you have seen multiple neurosurgeons who have
told you that you needed surgery, and you want to explore every option. The Plan denied your request. The
Plan says one visit can be approved, as a second opinion is covered.
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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no medical need for any additional out-of-network neurosurgery visits. The neurosurgical care
may be safely provided in network. There is no need for out of network referral.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continued referral with an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam and an ophthalmic ultrasound (92014, 76514) provided on August 13, 2021.
You asked the Plan to waive the copayment for the eye exam and an ophthalmic ultrasound. You say that the services should be covered as you were not told why the tests were being performed and whether there would be a copayment. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for Outpatient diagnostic tests and therapeutic services and supplies and a $30 copayment for Vision care.
You have been asked to pay a $30 copayment for an eye exam and a $11.41 copayment, which is less than the
$30 stated in the Plans contract for an ophthalmic ultrasound. Eye exams fall within the Vision care benefit
category and ophthalmic ultrasounds 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 an eye exam and an
ophthalmic ultrasound (92014, 76514) provided on August 13, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided September 13, 2021 to October 13, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you have been getting great satisfaction from seeing this provider and you do not understand why these services are not covered. The Plan denied your request. The Plan says the services were provided by an ineligible provider. Licensed professional counselors are not eligible to perform mental health services.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90837) provided September 13, 2021 to October 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing
provided on July 8, 2021, billed with code 88120.
You asked the Plan to pay for the FISH testing. You say that this is medically necessary. The Plan denied your request. The Plan says this was done for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal is a screening tool to detect evidence of cancer. This was provided for a diagnosis of urinary tract infection. There is no evidence that there was a specific sign/symptom of cancer for which this was ordered. As such, it is considered a screening test. Therefore, we decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) testing provided on July 8, 2021, billed with code 88120.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on July 15, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you feel that you did not receive the proper care and you should not have to pay for the visit. 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 $90 copayment for each emergency room visit. You have been asked to pay a $90 copayment for the ER visit. ER visits fall 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 (ER) visit provided on July 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73221).
You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found the record does not indicate the occurrence of acute injury. The physical examination noted in the record does not support the need for the requested study at this time. The record does not indicate that a trial of conservative therapy has been failed. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the shoulder (73221).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthodontic retention (D8680) provided on May 6, 2021.
You asked the Plan to pay for the dental service. You say that you have been wearing a retainer for 25 years. You say that the retainer keeps your teeth in alignment. You also say that you need a new one since your current one no longer fits properly. The Plan denied your request. The Plan says orthodontic retention is not a covered service.
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 orthodontic retention (D8680) provided on May 6, 2021
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay the $100 eyewear benefit allowance for eyeglasses provided on
May 11, 2021.
You asked the Plan to pay the $100 eyewear benefit allowance for eyeglasses. The Plan denied your request. The Plan says that your request is not a covered benefit because your records show that you did have an eye doctor visit as billed, and a prescription for your eyeglasses was provided.
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. Specifically, the Plan has not responded to our request to explain why the Plan did not pay the maximum Plan eyewear benefit allowance. Therefore, we decided that the Plan has to pay the $100 eyewear benefit allowance for eyeglasses provided on May 11, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 13, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on August 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an unspecified adjunctive procedure for a Covid fee (D9999) provided on October 12, 2021.
You asked the Plan to pay for an unspecified adjunctive procedure. You say that you understand the service requested is covered by your Plan and you have not had this service performed previously. The Plan denied your request. The Plan says the service requested is not a covered benefit with your 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.
We looked at the file and Medicare rules. The records show that the unspecified adjunctive procedure is a Covid fee. The records also show that a Covid fee is not covered by the Plan after July 1, 2021. Based on this information, we decided that the Plan's rules for coverage of an unspecified adjunctive procedure have not been met. Therefore, we decided that the Plan does not have to pay for an unspecified adjunctive procedure for a Covid fee (D9999) provided on October 12, 2021.