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

We decided that the Plan does not have to waive the copayments for a specialist visit and an X-ray provided on January 17, 2020.
You asked the Plan to waive the copayments for a specialist visit and an X-ray. You say that you are unhappy with the care you received and feel the tests were unnecessary. 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 $30 copayment for specialist visits. Your contract with the Plan also clearly says that you must pay a $35
copayment for X-rays. You had a specialist visit on January 17, 2020. Therefore, you are responsible to pay the $30 copayment. You received an X-ray on January 17, 2020. Therefore, you are responsible to pay the $35 copayment. The total amount you owe is: $65. You have been asked to pay the total copayment amount of $65 for a specialist visit and an X-ray. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An X-ray 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 copayments for a specialist visit and an X-ray provided on January 17, 2020.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for the inpatient care provided on March 24, 2020. We decided that the Plan does not have to pay for the inpatient care provided from March 25, 2020, through discharge.
You asked the Plan to pay for the inpatient care. The Plan says that the services were not medically necessary.
We decided that the Plan has to pay for the inpatient care provided on March 24, 2020.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient care provided on March 24, 2020, was medically reasonable and necessary. Our physician reviewer found that the enrollee is a 39-year-old woman with Unspecified Depressive Disorder, Acute Reaction to Stress, and Developmental Intellectual Disability, who was admitted to the hospital on 3/23/2020 with suicidal thoughts. The documentation supports that the enrollee initially met criteria for acute inpatient mental health treatment as this patient was initially shown to be a danger to herself. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pay for the inpatient care provided on March 24, 2020.
We also decided that the Plan does not have to pay for the inpatient care provided from March 25, 2020, through discharge.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient care provided on from March 25, 2020, through discharge, was not medically reasonable and necessary. Our physician reviewer found that the case file does not contain medical records from March 25, 2020, and March 26, 2020. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from March 25, 2020, through discharge.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine.
You asked the Plan to pre-approve Lidocaine. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Lidocaine.
Benefits for Lidocaine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
September 11, 2020, through September 28, 2020.
You asked the Plan to pay for the continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.
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 pay for the continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She had uncomplicated care to an unstageable right heel wound. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was dependent with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from September 11, 2020, through September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic office visit you had on October 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic office visit you had on October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for the intraoral procedures provided on January 15, 2020 to June 18, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the anesthesia for intraoral procedures. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for anesthesia for the intraoral procedures provided on January 15, 2020 to June 18, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a nuclear medicine study.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a nuclear medicine study.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for wound repair (12013) provided on September 17, 2020.
You asked the Plan to pay for wound repair. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the billed code.
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 12013 is simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm. We find that CPT code 12013 is not supported in the medical record. Specifically, the procedure note in the submitted records do not document the location on which the repair was performed. Without this information, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of
wound repair have not been met. Therefore, we decided that the Plan does not have to pay for wound repair (12013) provided on September 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging. 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 follows Medicare rules. Medicare rules say that myocardial perfusion studies performed based on the presence of risk factors in the absence of cardiac symptoms, cardiac abnormalities on physical examination, or abnormalities on cardiac testing (e.g., electrocardiographic tests, echocardiography, etc) will be considered screening and denied as not covered by Medicare. 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 myocardial perfusion imaging. Our reviewer says that the services are not medically necessary. Our physician reviewer found you have no symptoms of cardiac disease and there is no history provided of any prior cardiac events or cardiac revascularization procedures. You have risk factors for coronary artery disease (CAD) which are being well managed per the provider notes. Based on the guidelines, stress nuclear perfusion imaging in the absence of any symptoms or signs of cardiovascular disease and without any history of prior cardiac events or revascularization procedures would be considered not medically necessary and a screening test per the LCD which is not covered by CMS.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next Test Strip (A4253).
You asked the Plan to pre-approve Contour Next Test Strip. You say that you require the test strips. The Plan
denied your request. The Plan says there are preferred plan alternatives available for the diabetic test strips.
Medicare rules say that plans can require enrollees to get care from network preferred providers. The contract
with the Plan says that the Plan has to pre-approve care from non-preferred providers only in cases where there
are no preferred alternatives available or reasonable.
The requested provider in this case is not a preferred brand with the Plan. The Plan has preferred providers
available who can provide the items/services at issue in this appeal. Some examples can be found in your plan's
Pharmacy Coverage Policy. We found no exception, such as previous treatment or intolerance to the preferred
strips, that would require the Plan to pre-approve this brand of items/services. Therefore, we decided that the
Plan does not have to pre-approve Contour Next Test Strip (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
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 services at issue in this appeal. 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 the services provided by an out-of-network provider on September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan and does not have to waive the coinsurance for a Medicare Part B drug provided on December 22, 2020.
You asked the Plan to waive the copayment for a CT scan and to waive the coinsurance for a Medicare Part B drug. You say that you met the MOOP amount prior to receiving the services and disagree with 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 the MOOP amount for 2020 is $3,400. Your contract with the Plan also clearly says that you must pay a $275 copayment for advanced imaging services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a CT scan and a Medicare Part B drug on December 22, 2020, The record shows that you had only paid $43.27 toward the $3,400 MOOP amount prior to receiving the services. Therefore, you are responsible to pay your share of the cost-sharing charges. You received a CT scan on December 22, 2020. Therefore, you are responsible to pay the allowed amount of $249.80, which is less than the $275 copayment. You received a Medicare Part B drug on December 22, 2020. The total allowed amount is $4,544.76 and 20% of that is $908.96. The total amount you owe is: $1,158.76.
You have been asked to pay the total amount of $1,158.76 for a CT scan and a Medicare Part B drug. A CT scan falls within the outpatient hospital services benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 CT scan and does not have to waive the coinsurance for a Medicare Part B drug provided on December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure (43644) and the upper gastrointestinal endoscopy (43235) for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee would benefit significantly from bariatric surgery. The Plan denied your request. The Plan says that the member does not meet Medicare guidelines for bariatric surgery.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35;
(2) at least one co-morbidity related to obesity; and (3) been unsuccessful with medical treatment for obesity. We looked at the file and Medicare rules. The file indicates the enrollee's most recent BMI is not greater than or equal to 35. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve laparoscopy, surgical, gastric restrictive procedure (43644) and the upper gastrointestinal endoscopy (43235) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a non-preferred brand of diabetic testing supplies provided on May 12, 2020.
You asked the Plan to pay for a non-preferred brand of diabetic testing supplies. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the non-preferred brand of supplies was not pre-approved and the code modifier KX is wrong.
Medicare rules say that plans can require enrollees to get preferred brands of diabetic supplies. The supplies are not the Plan preferred brand. The Plan did not pre-approve the items at issue. The KX modifier is incorrect. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for a non-preferred brand of diabetic testing supplies provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the frames and lenses purchased February 10, 2021.
You asked the Plan to pay an additional amount for the frames and lenses. You say that the claim should be reprocessed using the Plan's allowed amount as the cost of the frames and lenses. The Plan denied your request. The Plan says you are responsible for any amount over the $300 retail price of frames and lenses.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when up to the $300 retail price of frames and lenses. We looked at the file and the Plan's rules. The Plan contract clearly states that the $300 benefit allowance is based on the retail price of the frames and lenses. The retail price of the frames was $369. The Plan applied the $300 benefit toward the retail price, leaving an uncovered amount of $69. The Plan applied a 20% discount to the uncovered amount, leaving a balance of $55.20. The Plan contract states you are responsible for any amount over the $300 benefit allowance applied towards the retail price of the frames and lenses. Based on this information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. Therefore, we decided that the Plan does not have to pay an additional amount for the frames and lenses purchased February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for specialist services provided by a participating provider on November 9, 2020.
You asked the Plan to waive the deductible for specialist services. You say that you were told the Plan would cover this bill completely. The Plan denied your request. The Plan says the correct deductible amount has been applied.
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 $198 deductible for our plan has a deductible amount. The item or service you asked the Plan to waive the deductible for falls within the benefit category our plan has a deductible amount. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible for our plan has a deductible amount. This cost sharing is a contractual obligation that had not been met at the time specialist services was received on November 9, 2020. The total amount you are being asked to pay is $74.21. Therefore, we decided that the Plan does not have to waive the deductible for specialist services provided by a participating provider on November 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).
You asked the Plan to pre-approve the full mouth debridement. The Plan denied your request. The Plan says this service conflicts with another service in the enrollee's history.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, full mouth debridement (D4355) cannot be performed the same day or less than 1 calendar year after an evaluation (D0120, D0150). The record shows that the enrollee received a comprehensive oral evaluation (D0150) on April 12, 2021, and a full mouth debridement (D4355) now cannot be performed. Therefore, we decided that the Plan does not have to pre-approve a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).