Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the diagnostic radiology tests provided on August 8, 2019.
You asked the Plan to waive the coinsurance for the diagnostic radiology tests. You say that you should not be charged this much for a stress test that lasted three hours. 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 20% coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a total coinsurance amount of $281.46, which is less than the standard 20% of the allowed amounts for the diagnostic radiology tests. The total allowed amounts is $1,435.45. The diagnostic radiology tests 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 coinsurance for the diagnostic radiology tests provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on February 1, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthosis was not 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 pay for the shoulder-elbow-wrist-hand orthosis (L3960). Our physician reviewer found the medical records provided do not meet the requirements listed in the LCD/PIM for Medicare coverage of the shoulder-elbow-wrist-hand orthosis (L3960). 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 shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on February 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a health club membership.
You asked the Plan to pre-approve the health club membership. You say that the enrollee has diabetes and needs access to a gym for an exercise program and access to a pool for therapy. You say that the medical records provided support the importance of a gym membership to the enrollee's well-being and health. The Plan denied your request. The Plan says health club memberships are not covered by the enrollee's benefit plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Therefore, we decided that the Plan does not have to pre-approve a health club membership.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 10, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that if you knew about the copayment you would not have gotten it. You say that you cannot afford it. 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 $150 copayment for each Medicare-covered advanced radiology service. You have been asked to pay a $150 copayment for the CT scan. The CT scan 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 CT scan provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on August 19, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this provider has been your primary care physician since 2012 and is not a specialist. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for Medicare-covered in-network physician services. The Plan says you must pay a $50 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the office visit. The record shows that this provider is a family medicine physician. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on August 19, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the arthrocentesis provided on August 13, 2019 and the endoscopy provided on August 22, 2019.
You asked the Plan to waive the copayments for the arthrocentesis and endoscopy. You say that you should not have a copayment this high for a shot. You say that you don't agree with the bills. The Plan denied your request. The Plan says the copayments 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 $285 copayment for each covered surgery or observation room service in an outpatient hospital. You have been asked to pay a total of $391.78 for the arthrocentesis and endoscopy.
The arthrocentesis and endoscopy fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis and endoscopy are considered surgical procedures. 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 copayments for the arthrocentesis provided on August 13, 2019 and the endoscopy provided on August 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on January 9, 2019.
You asked the Plan to waive the copayment for the outpatient surgery services. You say that you feel you should not be responsible for this cost share amount. The Plan denied your request. The Plan says you received outpatient surgery on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.
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. We looked at the file and Medicare rules. The file shows you received outpatient surgery on January 9, 2019. You have been asked to pay a $130.78 copayment for the outpatient surgery services, which is less than the contracted $200 copayment amount. The outpatient surgery services fall within the Outpatient surgery 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 outpatient surgery services provided on January 9, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on August 16, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that all the nurse did was take your blood pressure. You say that you should not have to pay the copayment. 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 $90 copayment per visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you received an electrocardiogram during the emergency department visit. 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 ED visit provided on August 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you cannot walk independently, and have no support at home. The Plan denied your request. The Plan says you are able to ambulate up to 40 feet.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. The file shows that continued services were requested beyond January 8, 2020. 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 continued services. Our physician reviewer found that from a nursing perspective, you have stable vital signs and your blood sugars were controlled. There are no identifiable skilled nursing service needs. Regarding rehab services, you were at a standby assist level with functional mobility. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on July 31, 2019.
You asked the Plan to waive the copayment for the MRI. You say that you paid $25 at the office before the MRI and thought this was your only copayment. You say that you have never been billed this high for an MRI. 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 $275 copayment for each advanced imaging service. You have been asked to pay a $275 copayment for the MRI. The MRI 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 MRI provided on July 31, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on July 11, 2018.
You asked the Plan to pay for train of four testing. You say that this service was medically necessary. The Plan denied your request. The Plan says payment for this service is included in payment for other services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 95999 is not supported in the medical record. Specifically unlisted CPT code 95999 is not supported for train of four testing. According to CPT rules, train of four is included in other intraoperative neuromonitoring procedures and is not reported separately. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on July 11, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from April 3, 2019 to May 29, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file, Medicare rules, and the Plan's rules. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from April 3, 2019 to May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT, called "CyberKnife").
You asked the Plan to pre-approve SBRT. You say that you believe that whole-breast radiotherapy is too much treatment and too toxic for the enrollee, but CyberKnife enables precise dose distributions with extreme accuracy over a minimum number of treatments. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because SBRT is not medically necessary and this technology for treatment of the enrollee's condition is still being studied.
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 SBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the appeal describes the need to avoid whole breast radiation, but does not describe why SBRT is needed over more standard approaches of partial breast radiation. The safety and efficacy of SBRT compared to more standard approaches is unknown. This treatment remains investigational and is not the accepted standard of care for the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT, called "CyberKnife").
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from aggressive therapies in an IRF setting in order to return home safely. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's ongoing medication management, wound care, and daily therapy could be provided at a Skilled Nursing Facility (SNF) level of care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee is mostly minimum assistance for transfers and activities of daily living, and a less intensive, longer duration of therapy will allow for measureable gains to be attained within a predicted period. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and the copayment for the stress test provided on September 9, 2019.
You asked the Plan to waive the deductible and the copayment for the stress test. You say that you were never told the stress test would go towards your deductible. You say you were told this would be covered. 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. Your contract with the Plan says that there is a $750 deductible that applies towards stress tests and a $200 copayment after the deductible is met for each advanced imaging service (e.g., MRI, CT, and PET scan, nuclear medicine, and stress tests). The stress test you asked the Plan to waive the deductible and the copayment for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards stress tests. The allowed amount for the stress test is $1,035.43. The record shows $606.77 was applied to deductible, which satisfies the $750 deductible amount.
The remaining allowed amount is $428.66 ($1,035.43 - $606.77 = $428.66). Therefore, you are responsible for the $200 copayment after the deductible is met for each advanced imaging service (e.g., MRI, CT, and PET scan, nuclear medicine, and stress tests). ($606.77 + $200 = $806.77).
This cost sharing is a contractual obligation that had not been met at the time the stress test was received on September 9, 2019. Therefore, we decided that the Plan does not have to waive the deductible and the copayment for the stress test provided on September 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional week of SNF services.
You asked the Plan to pre-approve the additional SNF services. You say that you are requesting an additional week of SNF services in order to make arrangements for the member's living and medical needs. The Plan denied your request. The Plan says once the member has reached the 100-day benefit limit, they are no longer eligible for SNF care during this benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from September 9, 2019 through January 8, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period.The enrollee will be eligible for a new benefit period when they have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve an additional week of SNF services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient substance abuse services provided from August 11, 2019 through August 24, 2019.
You asked the Plan to pay for the outpatient substance abuse services. The Plan denied your request. The Plan says services by any provider or facility that is not recognized by Federal Medicare are excluded from coverage.
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 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 outpatient substance abuse services provided from August 11, 2019 through August 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for computed tomography (CT) scans (70491, 74178, and 71270) provided from July 10, 2019 to July 15, 2019.
You asked the Plan to waive the coinsurance for CT scans. You say that you should not have been required to get a CT Scan. The Plan denied your request. The Plan says these services processed 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 20% coinsurance for CT scans. You have been asked to pay $340.16 for CT scans (1,700.76 allowed amount x 20% = $340.16). 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 computed tomography (CT) scans (70491, 74178, and 71270) provided from July 10, 2019 to July 15, 2019.