Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on January 5, 2021, through January 10, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was 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 days one through six for inpatient hospital care. You have been asked to pay a $325 copayment for days one through six for inpatient hospital care ($325 x 5 = $1,625). This service falls within the inpatient hospital 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 inpatient hospital care provided on January 5, 2021, through January 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on January 4, 2021.
You asked the Plan to waive the copayment for the laboratory work. You say that this laboratory work was a part of your annual wellness blood work. You say the blood work should be free once a year. 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 $10 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the laboratory work was diagnostic in nature.
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 laboratory services provided on January 4, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from September 11, 2020, to October 22, 2020.

You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request.

The Plan says the Medicare data base shows the enrollee was in hospice from July 01, 2020 through current date. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered from September 11, 2020 through October 22, 2020. Per the regulations the claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee from September 11, 2020, to October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment outpatient surgery provided on February 17, 2021.
You asked the Plan to waive the copayment outpatient surgery. You say that the provider receptionist informed you that there was no charge for this visit. The Plan denied your request. The Plan says the copayment amount 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 $260 copayment for in-network outpatient surgery at an outpatient hospital facility. You have been asked to pay the allowed amount of $172.98, which is less than the $260 copayment for outpatient surgery. Outpatient surgery 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 outpatient surgery provided on February 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for chemotherapy provided on November 24,
2020.
You asked the Plan to waive the cost-share for chemotherapy. You say that you disagree with the charges.
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 10%
cost-share of the total cost up to a $300 quarterly maximum for Medicare Part B prescription drugs.
You have been asked to pay 10% of the total cost up to a $300 quarterly maximum for chemotherapy. The
allowed amount of the claim is $3,665.42, resulting in a cost-share obligation of $295.57. You have been asked
to pay a cost-share less than the Plan's contracted amount. Chemotherapy 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 cost-share for chemotherapy
provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 6, 2021.
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 January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit coded 99334 provided on September 4,
2020.
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as 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 99334 is domiciliary or rest home visit for the evaluation
and management of an established patient, which requires at least 2 of these 3 key components: A problem
focused interval history; A problem focused examination; Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.
Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver. We find that CPT code 99334 is not supported in the medical record. Specifically, this code was billed with a place of service of 12 (home). This code should be used with place of service 31 (Skilled nursing facility) if the enrollee is in a Part A skilled nursing facility stay, place of service 32 (nursing facility) if the enrollee does not have Part A skilled nursing facility benefits or if the enrollee is in a nursing facility or in a non-covered skilled nursing facility stay (e.g., there was no preceding 3-day hospital stay), place of service 54 (Intermediate Care Facility), or place of service 56 (Psychiatric Residential Treatment Center). The claim cannot be billed with the place of service billed. Based on this information, we decided that Medicare rules for coverage of the rest home visit have not been met. Therefore, we decided that the Plan does not have to pay for the rest home visit coded 99334 provided on September 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file does not support that the services were performed in the laboratory setting. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on July 17, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block services.
You asked the Plan to pre-approve the genicular nerve block services. You say that the enrollee's clinical history supports the need for the requested services. You say that, due to the continued failure of interventional pain management treatment, the enrollee will benefit from the Coolief Genicular Nerve Ablation to bilateral knees to treat her bilateral knee chronic pain. The Plan denied your request. The Plan says medical studies haven't proven that the requested services are 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. 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 genicular nerve block services. Our reviewer says that genicular nerve block services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic bilateral knee pain due to osteoarthritis. She has tried viscosupplementation in the past and more recently Zilretta without sustained improvement. She takes Mobic, Lidocaine patches and steroids. The request is for cooled thermal radio frequency ablation (RFA) of the genicular nerves.
Our physician reviewer found that these genicular nerve block services are considered an experimental/investigational procedure that is the subject of on-going clinical trials. 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 genicular nerve block services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 2, 2021, to January 25, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.
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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 2, 2021, to January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 24, 2020.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 24, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this device has deluxe features that exceed the enrollee's needs.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. At this time the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard medical therapy.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G Orthotic device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance service (A0999) provided October 2, 2020, October 16, 2020, and October 30, 2020.

You asked the Plan to pay for the non-emergency ambulance service. You say that medical transportation was required due to non-weight bearing condition. The Plan denied your request. The Plan says there is no documentation to support transportation via a personal vehicle, an ambulette or a wheelchair van would endanger the enrollee's health.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

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 non-emergency ambulance service. Our reviewer says that the service was not medically necessary. Our physician reviewer found records show the patient being able to stand, pivot, and transfer to stretcher.

The provided documentation does not support that other means of transport were contraindicated, such as a wheelchair van or private car, or that required expertise and special equipment during transport were needed.

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 non-emergency ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance service (A0999) provided October 2, 2020, October 16, 2020, and October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 2, 2020 by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 an office visit provided on December 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy rendered on January 12, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for the medical nutrition therapy rendered on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on January 13, 2021.
You asked the Plan to pay for the prefabricated stainless steel crown. You say that the enrollee is on a very limited income. The Plan denied your request. The Plan says this service is not covered under the Plan.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated stainless steel crown (D2931) provided on January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoskeletal ankle foot system.
You asked the Plan to pre-approve Endoskeletal ankle foot system, microprocessor-controlled feature,
dorsiflexion and/or plantar flexion control, includes power source (L5973) Right. You say that the enrollee
needs this prosthetic microprocessor foot. The Plan denied your request. The Plan says request for a K3
microprocessor foot does not meet Medicare criteria as reasonable and 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 endoskeletal ankle foot system,
microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source (L5973)
Right. Our reviewer says that the requested item is not considered medically reasonable and necessary in this
case. Our physician reviewer found the patient's expected level of amputation includes expected assistive
device with prosthesis of handrails and ramps. Expected ambulatory aids include cane, wheelchair, 4 WW. The
presence of the ambulatory aids do not support a K3 level of ambulation and therefore the L5973 criteria have
not been met per Lower Limb Prostheses - Policy Article (A52496) and per Social Security Act, Section 1862
(a)1(A) and the 42 CFR 411.15(k)
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion
and/or plantar flexion control, includes power source (L5973) Right have not been met. Therefore, we decided
that the Plan does not have to pre-approve endoskeletal ankle foot system.