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 transfer to an IRF is medically necessary for the enrollee to return home safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate 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 that 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided from July 14, 2020, to July 16, 2020.  You asked the Plan to pay for the self-administered drugs. You say that it appears to you that if the claims summary page is correct and that this is not a valid charge, that it is an attempt at balance billing which you believe is prohibited by the Plan's contract. The Plan denied your request. The Plan says the medications administered were a continuation of home medications. The Plan also says that Medicare Part B generally does not pay for self-administered drugs.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from July 14, 2020, to July 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for hearing aids provided on September 21, 2021.  You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says there is no coverage for hearing aids.  The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services.   Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on September 7, 2021, by an OON provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 office visit provided on September 7, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reduction surgery (19318) to be provided by an out-of-network provider.

You asked the Plan to pre-approve breast reduction. You say that the requested procedure is a necessity for your care. The Plan denied your request. The Plan says rules for coverage for out-of-network care have not been met.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve breast reduction surgery (19318) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the anoscopy procedure you had at an outpatient hospital facility on October 13, 2021.  

You asked the Plan to waive the copayment for the anoscopy procedure. You say that you are confused by the bill for this service.  You said that this was an in-network service and that you paid your $15 copayment on that date. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for the anoscopy procedure ($82.92) is less than your copayment obligation, you are responsible for the full allowed 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 $200 copayment for outpatient surgery at an outpatient hospital facility.   

You have been asked to pay a $200 copayment for the anoscopy procedure. The anoscopy procedure falls within the outpatient surgery at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the anoscopy procedure you had at an outpatient hospital facility on October 13, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the ultrasound provided by an in-network provider on September 13, 2021.  You asked the Plan to waive the coinsurance for the ultrasound. You say that you were not aware there was a cost share for this service. You say this causes financial hardship. The Plan denied your request. The Plan says you have been asked to pay 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 20% coinsurance up to $75 per day for Medicare-covered diagnostic radiology services.    You have been asked to pay $18.77 which is 20% of the allowed amount for the ultrasound. The allowed amount is $93.87. ($93.87 x 20% = $18.77). The ultrasound 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 coinsurance for the ultrasound provided by an in-network provider on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the simple extraction (D7140) provided on September 14, 2021.  You asked the Plan to pay for the extraction. You say that some of this service should be covered by your insurance. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan. The Plan also says that you did not contact the Plan prior to the service being rendered to verify benefits and provider eligibility.  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 simple extraction (D7140) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the eye exam (92012) ophthalmic biometry (92136) to be provided by an OON provider.  

You asked the Plan to pre-approve the vision services. You say that you need cataract surgery and have very dry eyesight. You need this appeal to be worked on urgently as your eyesight keeps getting worse. 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 pre-approve care from out-of-network providers only in cases involving emergencies, out-of-area urgent care and care that cannot be provided by network providers.  

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the eye exam (92012) ophthalmic biometry (92136) to be provided by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on October 6, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The service provided in this case was a telehealth specialist office visit rendered by an out-of-network provider.  The Plan contract states that an enrollee has the option of getting covered services through an in-person visit or by telehealth. If the enrollee chooses to get one of these services by telehealth, they must use a network provider. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nourianz 40MG tablet.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says Nourianz is a self-administered drug. The Plan states the enrollee does not have pharmacy (drug) benefits administered by the health plan, but the enrollee does have another plan which provides its own pharmacy benefits.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nourianz 40MG tablet.

Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the deep sedation/general anesthesia (D9222 and D9223) provided on August 12, 2021.  

You asked the Plan to pay for the deep sedation/general anesthesia. You say that the enrollee's in-network dentist would not perform the work and advised them to go elsewhere for the services. The Plan denied your request. The Plan says there is no coverage for this service.  

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. The only type of anesthesia covered under the enrollee's plan is local anesthesia.      

Therefore, we decided that the Plan does not have to pay for the deep sedation/general anesthesia (D9222 and D9223) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services provided on April 30, 2021, and July 29, 2021.  You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.  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 did not pre-approve the service 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 ophthalmological services provided on April 30, 2021, and July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for podiatry services provided on October 25, 2021.  You asked the Plan to waive the copayment for the podiatry services. You say that it was a routine diabetic visit and should not have a copayment. 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 $45 copayment for each foot care visit.        The record shows you had a wound debridement and ingrown nail removal performed at this visit. These services go beyond the scope of a routine podiatry visit for diabetics. Therefore, you have been asked to pay a $45 copayment for the podiatry services. The podiatry services falls within the Podiatry 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 podiatry services provided on October 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 29, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services. You say that services were rendered to the enrollee, and you should be reimbursed. The Plan denied your request. The Plan says the enrollee was referred by a non-participating provider to an out-of-network provider. Therefore, services were 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 the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 29, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve all-inclusive clinic visits (T1015) and therapeutic behavioral services (H2019).  You asked the Plan to pre-approve all-inclusive clinic visits and therapeutic behavioral services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Codes T1015 and H2019 each have a status indicator of "I" on the Physician Fee Schedule. This means that codes T1015 and H2019 are invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of all-inclusive clinic visits and therapeutic behavioral services have not been met. Therefore, we decided that the Plan does not have to pre-approve all-inclusive clinic visits (T1015) and therapeutic behavioral services (H2019).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a stress test and to waive the coinsurance for medical supplies provided on September 10, 2021.  

You asked the Plan to waive the copayment for a stress test and to waive the coinsurance for medical supplies. You say that you already paid $150 and are now receiving more charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment for non-radiological diagnostic services and 20% coinsurance for medical supplies.   

You received a stress test on September 10, 2021. Therefore, you are responsible to pay the $30 copayment.  

You received medical supplies on September 10, 2021. The total allowed amount is $472 and 20% of that is $94.40.   

The total amount you owe is: $124.40.   

You have been asked to pay the total amount of $124.40 for a stress test and medical supplies. A stress test and medical supplies 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 stress test and to waive the coinsurance for medical supplies provided on September 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of implantable defibrillator pulse generator only; with existing single lead (CPT code 33240), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee is constantly in multiple fibrillations and has PBC's. You state the enrollee has been in the emergency room quite some time and is not a candidate for anticoagulants. The Plan denied your request. The Plan says the enrollee does not have ventricular tachycardia/fibrillation, nor do they have cardiomyopathy.  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 service. Our physician reviewer found the ejection fraction is 55-60% by echocardiography. Review of clinical documents does not show that the enrollee meets implant criteria for defibrillator insertion according to current guidelines. In the absence of such documentation, implantation of an automatic defibrillator would not be considered medically necessary in the management of this enrollee.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of implantable defibrillator pulse generator only; with existing single lead (CPT code 33240), for the enrollee.