Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99204)
provided on December 17, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you have to pay a copayment when
the claim was already paid during the pandemic. 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 physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $40 copayment for an office visit with a specialist. The EOC confirms $40 is the
required copayment for this service. The Plan confirms when they extended the cost-share waiver they had in
effect for the pandemic, it only covered primary care provider (PCP) services through December 31, 2020. An
office visit with a specialist falls within the physician/practitioner services, including doctor's office visits 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 office visit with a specialist
(99204) provided on December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 12, 2021.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral complete series of radiographic images. You say that you have dental allowance left to cover these services. The Plan denied your request. The Plan says the comprehensive oral evaluation is a covered benefit, but you have exceeded the frequency limit of one every 3 years. The intraoral complete series of radiographic images is a covered benefit, but you have exceeded the frequency limit of one every 5 years.
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. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral complete series of radiographic images have not been met. Specifically, the record shows that you had exceeded the frequency limit prior to these services on January 28, 2021. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral complete series of radiographic images (D0210) provided on February 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthosis (powered upper extremity range of
motion assist device, L8702).
You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested item is experimental/investigational.
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 a MyoPro orthosis. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that at this time the requested robotic orthosis is not the standard of care in weakness secondary
to multiple sclerosis. 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. There is insufficient evidence in
the medical literature that the MyoPro orthosis will improve the long term outcomes for the enrollee, improve
weak arm function, or be safe for long term use.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MyoPro orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro orthosis (powered upper extremity range of motion assist device, L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the myoelectric elbow wrist hand finger orthosis, MyoPro Motion G device (L8702).
You asked the Plan to pre-approve the orthosis. You say that the myoelectric brace requested for the enrollee fully complies with all the reasonable and necessary provisions. The Plan denied your request. The Plan says this item is considered experimental and investigational. Medical studies have not proven that the device is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the myoelectric elbow wrist hand finger orthosis, MyoPro Motion G device (L8702).
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 these services are medically necessary. The Plan denied your request. The Plan says that your functional status and mobility skills have progressed such that you do not have complex rehabilitation needs.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall and was discharged to skilled nursing on 7/17/21. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on December 1, 2020.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges because you only had three visits and are being charged for four. 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 $35 copayment for outpatient rehabilitation services. 

The record shows that you received outpatient rehabilitation services on December 1, 2020. Therefore, you are responsible to pay the allowed amount of $31.68, which is less than the $35 copayment.

You have been asked to pay $31.68 for outpatient rehabilitation services. Outpatient rehabilitation services 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 outpatient rehabilitation services provided on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the review indicates that the record does not that at the time of inpatient 
admission the admitting physician reasonably expected that your necessary hospital care (including earlier ED 
and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on April 20, 2021.

You asked the Plan to waive the copayment for the arthrocentesis. You say that this is a discrepancy between what the copayment would have been if it had been in a primary care office and in the hospital. You say that the issue was not completely explained, and it was charged as surgery instead of a visit. 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 $325 copayment for a surgical visit in an in-network hospital.

You have been asked to pay a $325 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical service that was billed by the hospital. 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 arthrocentesis provided on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on May 8, 2020, and billed under codes 87486, 87496, 87498, 87541, 87581, 87640 and 87798.
You asked the Plan to pay for lab services provided to the enrollee. The Plan says while codes 87631 and U0004 were paid, codes 87486, 87496,87498, 87541, 87581, 87640, and 87798 could not be paid due to a place of service (POS) code error. The Plan states the POS designation identifies the location where the laboratory service was provided, except in the case of an Independent or a Reference Laboratory.
An Independent or Reference Laboratory must show the place where the sample was taken (if drawn in an Independent Lab or a Reference Lab, POS 81 is reported; if drawn in a hospital inpatient setting, the appropriate inpatient POS is reported). All entities billing for laboratory services should append identifying modifiers when appropriate, in accordance with correct coding. If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it reports the code for the inpatient (POS code 21) or outpatient hospital (POS code 22), respectively. If an independent lab bills, the place where the sample was taken is reported. An independent laboratory taking a sample in its laboratory shows "81" as the POS.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, a portion this claim could not be paid due to an issue with the POS code reported. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 8, 2020, and billed under codes 87486, 87496, 87498, 87541, 87581, 87640, and 87798.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is noted to be functioning at/near her baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for intravitreal injections provided on September 25, 2020, and December 8, 2020.
You asked the Plan to waive the copayments for intravitreal injections. You say that you do not understand why the Plan paid so little. 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 $450 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. You received an intravitreal injection at an outpatient hospital facility on September 25, 2020. An intravitreal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the billed amount of $284, which is less than the $450 copayment.
You received an intravitreal injection at an outpatient hospital facility on December 8, 2020. An intravitreal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the billed amount of $303, which is less than the $450 copayment. The total amount you owe is: $587. You have been asked to pay the total copayment amount of $587 for intravitreal injections. Intravitreal injections fall within the outpatient surgery and other medical 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 copayments for intravitreal injections provided on September 25, 2020, and December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission is not medically necessary.
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. The enrollee was admitted for surgical repair of an acetabular facture after a fall. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee requires supervision for safety. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee's fingers crack when she
performs fingerstick glucose readings, which could cause infections. The Plan denied your request. The Plan
says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood
glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent
self-adjustment of insulin dosage based on the blood glucose testing results.
Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not
been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous
glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the omalizumab injection and chemotherapy administration provided on January 29, 2021.
You asked the Plan to waive the cost for the omalizumab injection and chemotherapy administration. You say that you are reporting a bill. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare Part B chemotherapy drugs and a $35 copayment for each Medicare-covered specialist office visit. You have been asked to pay a total of $479.01 for the omalizumab injection and chemotherapy administration.
The omalizumab injection falls within the "Medicare Part B prescription drugs" benefit category. The chemotherapy administration falls within the "Physician/Practitioner services, including doctor's office visits" 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 cost for the omalizumab injection and chemotherapy administration provided on January 29, 2021.