Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wrist/hand/finger brace provided on December 5, 2019.
You asked the Plan to waive the coinsurance for the wrist/hand/finger brace. You say that you were not informed the provider was out-of-network. You say that you shouldn't have to pay this amount. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered item. You have been asked to pay $45.43, which is 20% of the allowed amount for the wrist/hand/finger brace. The allowed amount is $227.17 (20% x $227.17 = $45.43). The wrist/hand/finger brace falls within the "Durable medical equipment (DME) and related 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 coinsurance for the wrist/hand/finger brace provided on December 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-rays provided on January 6, 2020.
You asked the Plan to waive the copayment for the x-rays. You say that you should not be charged an x-ray. You say you have never been billed or paid for a x-ray since you have had this insurance. The Plan denied your request. The Plan says you have been charged 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 $20 copayment for Medicare-covered x-rays. You have been asked to pay a $20 copayment for the x-rays. The x-rays fall 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 copayment for the x-rays provided on January 6, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the enrollee would not be as independent with separate toggle switches due to weakness and poor activity tolerance. The Plan denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches.
The Plan follows Medicare rules. Medicare rules state that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Documentation shows that the enrollee has normal range of motion and 3/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. This means that Medicare rules for coverage of a power wheelchair upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on November 5, 2019.
You asked the Plan to waive the coinsurance for the office visit. You say that you asked what provider was in-network. You say that your copayment should only be $10. The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for provider and professional services at an out-of-network PCP's office or specialist's office. You have been asked to pay $36.02, which is 50% of the allowed amount for the office visit. The allowed amount is $72.05 (50% x $72.05 = $36.02). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is out-of-network. 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 the office visit provided on November 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that You say that you would like this appeal reprocessed and approved for payment. 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 has network providers available who can provide 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 November 5, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 19, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an oral exam (D0120) provided on November 20, 2019.
You asked the Plan to pay for the oral exam. You say that you would like reconsideration because one of your previous appointments was not an exam. The Plan denied your request. The Plan says you were not eligible for an additional exam on this date of service.
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. The health Plan covers two oral exams per calendar year. The record indicates that you had oral exams on May 15, 2019 and August 9, 2019. The additional oral exam exceeds frequency limitations. Therefore, we decided that the Plan does not have to pay for an oral exam (D0120) provided on November 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 49002 provided on August 16, 2019.
You asked the Plan to pay for CPT code 49002. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 49002.
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 49002 is Reopening of recent laparotomy. We find that CPT code 49002 is not supported in the medical record. Specifically, medical records were not provided with an August 16, 2019 date of service after multiple attempts were made by the Plan. Based on this information, we decided that Medicare rules for coverage of CPT code 49002 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 49002 provided on August 16, 2019.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 you are generally medically stable. You required stand-by assistance with bed mobility and transfers. You tolerated 20 minutes of therapy with rest breaks. You required close supervision with walking 250 feet times 10 feet with a rolling walker. There is no evidence of need for supervision by physical medicine and rehabilitation physician or needs of acute rehab nursing care. While you may benefit from further physical therapy and occupational therapy, you do not require an intensive therapy program. Your therapy needs can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ablation therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ablation therapy. You say that this is a continuation of care. The Plan denied your request. The Plan says these services can be provided 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 ablation therapy to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat low dose computed tomography (LDCT) scan for lung cancer screening.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that LDCT for lung cancer screening is covered for enrollees who have quit smoking within the last 15 years. We looked at the file and Medicare rules. The file shows that the enrollee quit smoking 23 years ago. 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 a repeat low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hand surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve hand surgery. You say that you went to the only in-network doctor and you did not like the care you received. The Plan denied your request. The Plan says there are in-network provides available for these services.
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 hand surgery to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
You asked the Plan to pre-approve the power wheelchair Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377). You say that the upgraded electronics are necessary for the power chair to operate the power seating features. The Plan denied your request. The Plan says although there are three approved power options on this wheelchair (tilt, recline and elevating leg rests), there is not a medical need to control these power options through the joystick. The power options come with their own switches.
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is medically necessary. Documentation shows that the enrollee has normal range of motion and 4/5 strength in the bilateral upper limbs. Upper limb strength and range of motion are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. This means that Medicare rules for coverage of power wheelchair upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle (POV).You asked the Plan to pre-approvethese services. You say that you have extensive medical conditions and ailments.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a POV is covered when specific criteria are met.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 these services. Our reviewer says that you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you were recently admitted to the hospital in January of 2020 after a motor vehicle crash and leg fractures. You are now stable with no deficits as of January 24, 2020. The records do not support that you would not be able to operate a lesser device, such as a standard wheelchair; therefore, the POV is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. 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-approvea power operated vehicle (POV).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the spinal injection provided on December 2, 2019.
You asked the Plan to waive the deductible for the spinal injection. You say that you were unaware of all the various ways you would have to pay these bills. You say this is an outrageous bill for an injection. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
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 $750 deductible that applies towards spinal injections.
The spinal injection you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the spinal injection. This cost sharing is a contractual obligation that had not been met at the time the spinal injection was received on December 2, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a the spinal injection provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from December 18, 2019 through December 20, 2019.
You asked the Plan to waive the copayment for the observation stay. You say that you were admitted to the hospital as an inpatient. You say that you disagree with the observation status. 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 for outpatient hospital observation services. You have been asked to pay a $350 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" benefit category. The records show that you were admitted to outpatient observation. 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 observation stay provided from December 18, 2019 through December 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. You were trained in Foley care and this does not require daily skilled nursing services only in a SNF. You are at a functional level that does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on September 3, 2019.
You asked the Plan to pay for drug tests. You say that these tests meet medical necessity criteria according to guidelines. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the ordering provider did not submit progress notes needed to determine the clinical utility of the testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these services would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of these tests. Therefore, the Plan has not shown that its decision to deny payment for these tests is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for drug testing provided on September 3, 2019.