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

We decided that the Plan does not have to waive the copayment for surgical pathology services provided on September 5, 2019.
You asked the Plan to waive the copayment for surgical pathology services. You say that you do not know why you are being charged for this. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay up to a $250 copayment for outpatient hospital services/most outpatient hospital services. You have been asked to pay a $250 copayment for surgical pathology services. Surgical pathology services fall within the outpatient hospital services/most outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for surgical pathology services provided on September 5, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on August 22, 2019.
You asked the Plan to pay for the office visit. You say that you do not understand why this was denied. The Plan denied your request. The Plan says that a decision on this case was not made within the 60 day time frame.
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. 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 forward any medical records. Although it is noted that the medical director approved the appeal, it is not documented that payment was made or was pending. Without any documentation to support denial, we find that the rules for payment of this service have been met. Therefore, we decided that the Plan has to pay for the office visit provided on August 22, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 22, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you should not be charged for blood draws. The Plan denied your request. The Plan says the primary care physician copayment was applied in error and the Plan will not reprocess the claim.
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 15% of the cost for Medicare-covered benefits. You have been asked to pay a $15 copayment, which is less than the standard amount, for the laboratory work. The laboratory work falls within the "Outpatient hospital services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory work provided on August 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the circulating tumor cell (CTC) assay provided to the enrollee on February 28, 2019.
You asked the Plan to pay for the CTC assay. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CTC testing for all malignant diagnoses will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Per LCD L35710, the requested CTC testing is not medically reasonable and necessary, and therefore non-covered. Therefore, we decided that the Plan does not have to pay for the circulating tumor cell (CTC) assay provided to the enrollee on February 28, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on February 10, 2020 for confusion, unsteady gait, and aphasia. She needs minimal assist with bed mobility, supine to sit, and gait with a rolling walker. The complexity of her nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. She may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forneuromuscular junction testing (95937), needle electromyography (95870), and somatosensory testing (95938) provided on October 29, 2019.You asked the Plan to pay forneuromuscular junction testing, needle electromyography, and somatosensory testing. You say that these services should be paid.The Plan denied your request. The Plan says Medicare rules for payment have not been met.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. The record shows that these services were rendered while the enrollee was inpatient. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing, needle electromyography, and somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay forneuromuscular junction testing (95937), needle electromyography (95870), and somatosensory testing (95938) provided on October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that they do not cover outpatient prescription drugs.
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 Repatha for the enrollee.
Benefits for this drug 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ivermectin.
You asked the Plan to pre-approve the Ivermectin. You say that this drug is medically necessary for the
treatment of the member's condition. The Plan denied your request. The Plan says drug coverage is limited to
Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ivermectin.
Benefits for the Ivermectin 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain provided on September 4, 2019.
You asked the Plan to pay for the palliative (emergency) treatment of dental pain. You say that you were never informed of what was needed and you were not notified that the service was not a covered benefit of your plan. You also say that this was not an emergency and the provider should have notified you that the procedure was not covered. The Plan denied your request. The Plan says this service is not covered by your 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 palliative (emergency) treatment of dental pain provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 17, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code October 17, 2019. This code is listed with a status
indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the enrollee appears to be back at her baseline level of function from a physical therapy standpoint.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for PT provided from September 3, 2019 to September 24, 2019.
You asked the Plan to waive the copayment for PT. You say that you thought that you would only owe a $10 copayment per each visit. 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 $10 copayment for outpatient rehabilitation services provided in a specialist's office or comprehensive outpatient rehab facility and a $40 copayment when provided in an outpatient hospital facility. You received PT at an outpatient hospital facility from September 3, 2019 to September 24, 2019 for a total of 6 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $240.00. You have been asked to pay the total copayment amount of $240.00 for PT. PT falls within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for PT provided from September 3, 2019 to September 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) provided to the enrollee on September 16, 2019.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says PET procedure are only allowed three times for the same diagnosis.
The Plan must follow Medicare rules. Medicare rules say that Medicare may also cover up to three FDG PET scans when used to guide subsequent management of cancer treatment after completion of initial anti-cancer therapy.
We looked at the file and Medicare rules. The records show that the enrollee received PET scans on July 11, 2018, January 9, 2019, May 20, 2019, and September 16, 219. In this case, there were insufficient medical records provided to show that more than three scans were medically reasonable and coverable. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) provided to the enrollee on September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 2, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You submitted your bill for review. 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 one-way Medicare-covered ground trip. You have been asked to pay $74.29, which is 20% of the allowed amount for the ambulance transport. The allowed amount is $371.47 (20% x $371.47 = $74.29). The ambulance transport falls within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the office visit and annual wellness visit you had with an out-of-network provider on March 4, 2019, and April 30, 2019.
You asked the Plan to adjust the cost share. You say that you were told the provider was in-network. The Plan denied your request. The Plan says you are responsible for the cost share.
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% coinsurance for an out-of-network annual wellness visit. Review of the file shows that you had an out-of-network PCP visit and annual wellness visit on March 4, 2019, and April 30, 2019. You have been asked to pay a $40 copayment for the PCP visit and a 30% coinsurance for the annual wellness visit. 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 adjust the cost share for the office visit and annual wellness visit you had with an out-of-network provider on March 4, 2019, and April 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit with the physician, on
October 22, 2019.
You asked the Plan to waive the deductible for an office visit. You say that you met your deductible amount
and disagree with the deductible 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. Your
contract with the Plan says that there is a $500 deductible for physician/practitioner services, including doctor's
office visits.
You had an office visit on October 22, 2019. The record shows that you had only paid $333.55 toward the $500
deductible at the time services were received. Therefore, you are responsible to pay the remaining deductible
balance of $166.45.
The item or service you asked the Plan to waive the deductible for falls within the benefit category
physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $500 deductible for physician/practitioner services, including doctor's
office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was
received on October 22, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an
office visit with the physician, on October 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SimplyGo portable oxygen concentrator system.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen concentrator for travel, to go outside, to walk in the park, or grocery shop. The Plan denied your request. The Plan says you received a stationary oxygen system with portable tanks that meet your in-home needs.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The record shows that you have a stationary oxygen system with refillable portable tanks. The record shows this stationary oxygen system with refillable portable tanks meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Medicare only covers home oxygen for in-home needs. Therefore, we decided that the Plan does not have to pre-approve a SimplyGo portable oxygen concentrator system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the medical eye exam with photos provided
on September 18, 2019.
You asked the Plan to waive the deductible for the medical eye exam with photos. You say that you went for a
routine eye exam. You say you want to know why your bill was not paid. 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 $1,000 deductible that applies towards out-of-network Medicarecovered
eye exams.
The medical eye exam with photos you asked the Plan to waive the deductible for falls within the "Vision care"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a
$1,000 deductible that applies towards out-of-network Medicare-covered eye exams. The record shows the
provider is out-of-network and you had diagnosis of age-related cataracts and glaucoma which makes the exam
medical in nature.
This cost sharing is a contractual obligation that had not been met at the time the medical eye exam with photos
was received on September 18, 2019. Therefore, we decided that the Plan does not have to waive the deductible
for the medical eye exam with photos provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve visual field assessment device.You asked the Plan to pre-approve visual field assessment device. You say that you are requesting reconsideration to provide provider with in-network benefits as it is the only facility in the world that can render this service to the enrollee.The Plan denied your request. The Plan says this services is not considered medically reasonable and necessary by Medicare.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that plans can require enrollees to get care from network providers.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of visual field assessment device have not been met.Therefore, we decided that the Plan does not have to pre-approve visual field assessment device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions provided on March 12, 2019.
You asked the Plan to pay for the alveoloplasty. You say that you were told that this service would be partially covered. You also say that this surgery was due to cancer and you feel it was medically necessary. The Plan denied your request. The Plan says the services received were related to tooth extraction, and are not covered by your plan nor Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the alveoloplasty in conjunction with extractions provided on March 12, 2019.