Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an astigmatism-correcting function for an intraocular lens (V2787) provided on June 11, 2020.
You asked the Plan to pay for the astigmatism correcting function. You say that you have already paid a large sum to the provider for these services, and believed your bill was paid in full. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an astigmatism-correcting function for an intraocular lens (V2787) provided on June 11, 2020.
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 this is badly needed. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on December 21, 2020.
You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the copayment.
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 copayment for lab services provided in a freestanding laboratory facility. Review of the file shows that were provided lab services on December 21, 2020. Per your contract with the Plan, there is a $20 copayment for lab services at a freestanding laboratory facility. This cost sharing is a contractual obligation that you agreed to pay when you enrolled in plan name. However, the Medicare allowed amount for these services was $17.53. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $17.53 for these services. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the lab services you received on December 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries provided on June 24, 2020 and July 22, 2020.
You asked the Plan to waive the copayments for the cataract surgeries. You say that you are requesting reimbursement for the cataract surgeries. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each covered surgery in an in-network ambulatory surgical center. You have been asked to pay a $225 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including 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 the cataract surgeries provided on June 24, 2020 and July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gym membership.
You asked the Plan to pay for the gym membership. You say that you thought the gym was non-participating. The Plan denied your request. The Plan says It is your responsibility to continuously verify if the out-of-network fitness center you are using joins the network.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only The Plan provides an annual reimbursement allowance towards paid memberships at non-participating fitness clubs and exercise centers, up to $150. The Plan's rules for coverage of gym benefits have not been met because the health club in this case is a participating fitness club. The annual reimbursement is only applicable towards memberships at non-participating fitness clubs. Therefore, we decided that the Plan does not have to pay for the gym membership.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for immunohistochemistry antibody slide (88344) provided on December 9, 2020.
You asked the Plan to pay for the immunohistochemistry antibody slide. You say that you would like reconsideration based on the documentation submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 88344 is immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure. 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 immunohistochemistry antibody slide. Our reviewer says that CPT code 88344 does not meet criteria for billing or reimbursement consideration. Our physician reviewer found in this case, CPT code 88360, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, was also billed. The documentation does not support that 88344 was a separate and distinct procedure. 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 immunohistochemistry antibody slide have not been met. Therefore, we decided that the Plan does not have to pay for immunohistochemistry antibody slide (88344) provided on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral device (E0486) provided on September 23, 2020.
You asked the Plan to pay for an oral device. You say that this was medically necessary. The Plan denied your request. The Plan says a physician order and proof of delivery have not been submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order and proof of delivery for the item provided in this case. These documents are absent from the submitted records. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an oral device (E0486) provided on September 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 20, 2020, to October 23, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the hospital filed the wrong code for the medications that you received in the hospital. You say that they should have been Medicare "D". The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 20, 2020, to October 23, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services provided on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not eligible for replacement until May 2023.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you received a power wheelchair in May of 2018. The documentation does not support that the requested wheelchair in the same billing category is medically necessary, or that your condition has changed significantly that require a replacement in less than five years. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for the transthoracic echocardiography provided on
November 17, 2020.
You asked the Plan to waive the copayment for the transthoracic echocardiography. You say that you have no
copayment for an outpatient procedure at the hospital. The Plan denied your request. The Plan says that the
$200 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). The transthoracic echocardiography is considered a diagnostic test,
not a surgical procedure. Your contract with the Plan does not say in clear and accurate terms how much you
should expect to pay for other outpatient diagnostic tests.
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $200
copayment for a diagnostic test. The Plan contract does not clearly say how much enrollees must pay for other
outpatient diagnostic tests. This means that the Plan did not follow Medicare rules for disclosure of cost sharing
information. Therefore, we decided that the Plan has to waive the copayment for the transthoracic
echocardiography provided on November 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF services provided from August 6, 2020, through August 12, 2020.

You asked the Plan to waive the copayment for the SNF services. You say that you told them you wanted to go home when your benefits ended. You say that you should not have to pay this amount. 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 $0 copayment per day for days 1-20 and a $160 copayment for days 21-100 at an in-network and out-of-network provider. You have been asked to pay a $960 copayment for the SNF services.

Date of Service
SNF Days
Number of Days
Copayment
Member Liability

July 17, 2020- August 5, 2020
1-20
20
$0/day
$0

August 6, 2020- August 12, 2020
21-26
6
$160/day
$960

TOTAL:
$960

The SNF services fall within the "Skilled nursing facility (SNF) 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 the SNF services provided from August 6, 2020, through August 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 27, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because the enrollee had COVID-19.The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for ambulance services. 

The enrollee has been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on November 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (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 enrollee's medical needs are being met in the current acute setting.

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 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. 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 long term acute care hospital (LTACH) services for the enrollee.
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 IRF care is medically necessary for the enrollee's condition.The Plan denied your request. The Plan says rules for IRF care have not been met.

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 the patient was admitted to an acute care hospital for a stroke and congestive heart failure. Their medical problems are stable. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for audiology services provided on October 22, 2020.

You asked the Plan to pay for the audiology services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the audiology services. 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 audiology services provided on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 11, 2020, to March 12, 2020.

You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says inpatient care was not medically necessary.

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 pay for the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's 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 the acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 11, 2020, to March 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on June 8, 2020.

You asked the Plan to waive the copayment for the arthrocentesis. You say that you paid a $40 copayment at the time of service and are being billed for $310. You say that you should not be responsible for the bill.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 $350 copayment per date of service for an outpatient hospital facility.

You have been asked to pay a $350 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including 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 the arthrocentesis provided on June 8, 2020.