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

We decided that the Plan does not have to waive the copayments for the cardiac computed tomography (CT) scan you had on January 28, 2021, and the cardiac catheterization procedure you had on January 30, 2021, at an outpatient hospital facility.

You asked the Plan to waive the copayments for the cardiac CT scan and the cardiac catheterization. You say that you didn't know that your plan had these copayments. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the cardiac CT scan, the allowed amount for this service ($215.13) is less than your copayment, so you are responsible for the full allowed amount for this service.

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 diagnostic radiology services except ultrasounds and a $350 copayment for outpatient procedures. 

You have been asked to pay a $325 copayment for the cardiac CT scan and a $350 copayment for the cardiac catheterization. The diagnostic radiology copayment applies regardless of the reason for the CT scan. In addition, a cardiac catheterization is considered an outpatient procedure. 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 cardiac computed tomography (CT) scan you had on January 28, 2021, and the cardiac catheterization procedure you had on January 30, 2021, at an outpatient hospital facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis. The record indicates that imaging has demonstrated moderate to severe central stenosis at the L3-L4 level for which treatment is requested. The imaging also demonstrated lumbar scoliosis that is not quantified. The record does not indicate that the enrollee does not require operative treatment at no more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator, any type (E0466).

You asked the Plan to pre-approve a ventilator. You say that you are requesting an appeal as a Bipap will not be sufficient for the enrollee and a ventilator is needed. The Plan denied your request. The Plan says this request does not meet the medical necessity criteria.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate a diagnosis of COPD, but this is not confirmed by pulmonary function data, which do not show obstruction. The enrollee appears to have obesity hypoventilation syndrome as the primary cause of the chronic hyper carbic respiratory failure. This condition is treated with CPAP or BiPAP, not with a ventilator. The home ventilator is being used as BiPAP, which is not covered by Medicare.

Certain BiPAP devices can provide the AVAPS mode of support. 

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for diabetic shoe equipment provided by a participating provider on May 17, 2021.

You asked the Plan to waive the coinsurance for diabetic shoe equipment. You say that you would like this coinsurance waived. The Plan denied your request. The Plan says the correct coinsurance has been applied.

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 diabetes self-management training/therapeutic shoes and inserts. 

You have been asked to pay a 20% coinsurance of the allowed amount for diabetic shoe equipment. The total allowed amount is $118.44. The total amount you are being asked to pay is $23.69 ($118.44 x 20% = $23.69).diabetic shoe equipment falls within the diabetes self-management training/therapeutic shoes and inserts 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 diabetic shoe equipment provided by a participating provider on May 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), and endodontic therapy (D3320) provided on February 11, 2021.

You asked the Plan to pay for an intraoral periapical radiographic image, and endodontic therapy. You say that you want the Plan to consider paying for the services under your medical Plan because they are medically necessary. The Plan denied your request. The Plan says the services at issue are not a covered benefit.

Medicare generally does not cover dental services. The Plan follows the same rule. 

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for an intraoral periapical radiographic image (D0230), and endodontic therapy (D3320) provided on February 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a sacroiliac joint injection provided on March 22, 2021.

You asked the Plan to waive the copayment for a sacroiliac joint injection. You say that you request a lower copayment since this was just a a sacroiliac joint injection. 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 $265 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.

You received a sacroiliac joint injection at an outpatient hospital facility on March 22, 2021. A sacroiliac joint injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $265 copayment. 

You have been asked to pay a $265 copayment for a sacroiliac joint injection. A sacroiliac joint injection falls 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 copayment for a sacroiliac joint injection provided on March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brain imaging, positron emission tomography (PET) (78608).

You asked the Plan to pre-approve the PET scan. You say that your neurologist wanted to order a special x-ray for your brain The Plan denied your request. The Plan says the enrollee does not meet the criteria for a brain PET scan.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have a memory impairment. However, the applicable NCD states that PET/CT of the brain is only covered for use in differentiating between AD and FTD when an enrollee meets diagnostic criteria for both conditions. The records provided for review did not suggest that the enrollee otherwise would meet the diagnostic criteria for both AD and FTD. Nor is there readily a need to differentiate between the two. In as much the requirement of the NCD for coverage would not be met. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the brain imaging, positron emission tomography (PET) (78608).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on  
February 1, 2021. 
 
You asked the Plan to waive the copayment for the eye examination. The Plan denied your request. The Plan 
says the claim 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 a $30 
copayment for Vision Care. You have been asked to pay a $30 copayment for the eye examination. The eye examination falls within the 
Vision Care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for an eye examination 
provided on February 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on November 12, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not 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 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 lab work provided on November 12, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nutrition shakes.
You asked the Plan to pre-approve nutrition shakes. You say that nutrition shakes are medically necessary. The Plan denied your request. The Plan says nutrition shakes of any brand are not covered by the Plan or by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate for you to use, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve nutrition shakes
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy 100mg tablet.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.

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 Ubrelvy 100mg tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information 
(such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and 
(b). 
 
The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say 
that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to 
an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan 
contract says that enrollees must pay a $35 copayment for specialist visits, including telehealth visits. You can 
find this information in Chapter 4 on pages 56 - 57 of the Plan's 2021 Evidence of Coverage (EOC). We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 19, 
2021. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a telehealth visit and 
you should not be responsible for the 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 $35 
copayment for specialist visits, including telehealth services.  
 
You have been asked to pay a $35 copayment for a telehealth specialist visit. A telehealth specialist visit 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 a specialist visit provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that new foot orthotics are medically necessary. The 
Plan denied your request. The Plan says the medical records show that you have a large bunion and hammer 
toe. You have orthotics that you previously purchased out of pocket.  You state the current orthotics are warn 
and you would like them replaced.  
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
severe diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
The records show that you do not suffer from either of these conditions. Although orthotics may be appropriate 
for you to use, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we 
decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because
the member exceeds the criteria for admission to an LTACH and their needs cannot be met in a lower level of
care. The Plan denied your request. The Plan says there is no documentation that the enrollee will benefit and
improve with LTACH care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is
currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telemedicine facility fee provided by a participating hospital facility on April 21, 2021.

You asked the Plan to waive the copayment for telemedicine facility fee. You say that you already paid a $20 copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $100 copayment for outpatient hospital services. 

You have been asked to pay $27.02 which is less than your copayment amount of $100 for telemedicine facility fee. Telemedicine facility fee falls 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 copayment for telemedicine facility fee provided by a participating hospital facility on April 21, 2021.