Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for physical therapy (PT) visits (97110, 97140) provided on August 5, 2021, to August 30, 2021.  You asked the Plan to waive the copayment for PT visits. You say that you do not understand the charges for physical therapy. You thought each visit was a $20 copayment. You also say you would like a reduction in the charge for therapy services. The Plan denied your request. The Plan says the copayment 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 a $40 copayment for each Medicare-covered physical therapy visit.    You have been asked to pay a $40 copayment for each PT visit. The EOC confirms that $40 is the required copayment for this service. You had eight (8) PT visits for a total cost-share of $320 ($40 x 8 visits = $320). PT visits fall within the outpatient rehabilitation 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 physical therapy (PT) visits (97110, 97140) provided on August 5, 2021, to August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the pontic (D6245) and retainer crowns (D6740) provided on September 23, 2021.  You asked the Plan to pay more for the pontic and retainer crowns. You say that you would like to appeal the Plan's decision to deny payment for these services. The Plan denied your request. The Plan says your annual maximum benefit had been met.  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 Plan offers up to a $1,000 allowance for all covered dental services. The contract says that you are responsible for 100% of charges beyond the $1,000 allowance. The record shows that you met the annual maximum benefit while processing this claim for the September 23, 2021 date of service and your annual maximum benefit had been exhausted. Therefore, we decided that the Plan does not have to pay more for the pontic (D6245) and retainer crowns (D6740) provided on September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram (93010) provided on July 23, 2021.  You asked the Plan to pay for the electrocardiogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with an appropriate diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 93010 is not supported in the record. Specifically, this claim was not billed with a valid primary diagnosis code. Diagnosis codes under the branch of T36-T50 include a code first note. This means that the etiology diagnosis code must be billed first.  Based on this information, we decided that Medicare rules for coverage of the electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (93010) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded as 99100 and 99135 provided on April 21, 2021.  You asked the Plan to pay for the anesthesia services. You say that despite not receiving authorization, these services were medically necessary. The Plan denied your request. The Plan says no separate payment is made for these codes according to Medicare rules.  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 looked at the file and Medicare rules. In this case, these services have a Status Code of "B" under the Physician Fee Schedule indicating that these are Bundled Codes. Specifically, payment for these covered services is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 and 99135 provided on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient hospital observation services, per hour (G0378) provided from June 28, 2021, through June 29, 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 $325 copayment for outpatient hospital observation services.     You have been asked to pay a $325 copayment for the outpatient hospital observation 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 outpatient hospital observation services, per hour (G0378) provided from June 28, 2021, through June 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasonic guidance rendered on September 1, 2021.  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 not medically necessary.  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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee underwent trigger point injections to the bilateral paraspinous cervical rhomboid and trapezius muscle utilizing ultrasound guidance.  There is no documentation that she has a body mass index of greater than 40 or received epidural or facet joint injections. The ultrasonic guidance for the injections was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance rendered on September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Myopro device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of MyoPro orthotic device in the setting of a cerebrovascular accident with residual right spastic hemiparesis have not been demonstrated in the peer-reviewed literature.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase  participation in bimanual activities. At this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Myopro device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on July 12, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on July 12, 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.  You asked the Plan to pre-approve IRF care. You say that transfer to an IRF is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The services you need can be provided in a lower level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   Our physician reviewer found based on your current medical stability, you do not need physician supervision at least three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs are noted in the record. With your current functional level, you do not need intensive therapies consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. Documentation does not support the necessity for admission to an IRF; your rehab needs can be safely met in an alternate and lower intensity 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the assay of urea nitrogen rendered on September 20, 2021.
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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 84520 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the assay of urea nitrogen rendered on September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the computed tomography (CT) of the abdomen and pelvis (74176) provided on September 1, 2021.  You asked the Plan to waive the copayment for the CT of the abdomen and pelvis. You say that you would like reconsideration because this testing was not necessary so you should not be responsible for payment. The Plan denied your request. The Plan says the copayment was applied appropriately.  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 $150 copayment for Outpatient Diagnostic Tests.   You have been asked to pay a $150 copayment for the CT of the abdomen and pelvis. The CT Scan falls within the Outpatient Diagnostic Tests 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 computed tomography (CT) of the abdomen and pelvis (74176) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management analysis testing rendered on May 1, 2021.  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 not medically necessary.  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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had nonspecific gastritis/dyspepsia on chronic pain medication. The clinical value and effectiveness of the Foundation Pain Index in the setting of long-term drug therapy have not been demonstrated in the peer-reviewed literature. There is no documentation stating how the testing would directly impact the enrollee's treatment plan. The testing was not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the pain management analysis testing rendered on May 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 5, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for drug testing provided on May 5, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the knee surgery (27447) provided on September 29, 2021.  You asked the Plan to waive the coinsurance for the knee surgery. You say that the services should be covered as they were not as expensive before. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Outpatient hospital services.        You have been asked to pay a 20% coinsurance for knee surgery (the allowed amount is $13,178.86 X 20% = $2,635.7). The record indicates that these services were performed in an outpatient setting. Knee surgeries fall within the Outpatient hospital 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 coinsurance for the knee surgery (27447) provided on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 20, 2021.  You asked the Plan to pay for the comprehensive oral evaluation. You say that you had a toothache and needed an antibiotic. You also say that you feel this service was necessary to prevent infection and having teeth pulled. The Plan denied your request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been exceeded.  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, periodontal exam and comprehensive oral evaluation share a frequency limitation of one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on August 14, 2021, and your periodontal exam and comprehensive oral evaluation benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pay for IRF care. You say that you need inpatient rehabilitation to regain your strength and recover fully. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your care needs can be met in a skilled nursing facility.  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 pay for 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 your current medical stability, you do not need physician supervision three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehab nursing needs are noted in the record. With your current functional level, you do not need intensive therapies, consisting of at least three hours of therapy per day at least five days per week with a multidisciplinary approach to daily therapy. You are also noted to be confused in your ongoing therapy sessions, and you likely will not retain the learned skills and benefit from an IRF admission. Documentation does not support the necessity for admission to an IRF; your rehab needs can be safely met in an alternate and lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physical therapy services provided on September 17, 2019 to October 9, 2019 by an out-of-network (OON) provider.  You asked the Plan to pay for the physical therapy services. You say that you have attached notes for all dates of service. 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 the physical therapy services provided on September 17, 2019 to October 9, 2019 by an out-of-network (OON) provider.