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

We decided that the Plan does not have to waive the copayment for an office visit and ultrasound (99214,
76536) provided October 13, 2020.
You asked the Plan to waive the copayment for the office visit and ultrasound. You say that only the office visit
copayment should be applied. The Plan denied your request. The Plan says the correct cost sharing was
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 $40 for
specialist visits and $50 for diagnostic tests.
You have been asked to pay $40 for the office visit and $50 for the ultrasound. The office visit was a specialist
visit. The ultrasound falls within the diagnostic tests 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 an office visit and ultrasound (99214, 76536) provided October 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the chemotherapy drug services.

You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan says the cost share was applied based on plan benefits.

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% of the cost for Medicare Part B prescription drugs.

The file shows that the total cost for the services at issue was $34,055.60. A 20% cost share is $6811.12. You were charged $6265.87, which allowed you to meet the maximum out-of-pocket amount. The services fall 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 the chemotherapy drug services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitoring (CGM) system.

You asked the Plan to pay for the CGM. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the CGM was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397).

You asked the Plan to pay for a knee orthosis and a suspension sleeve. You say that the enrollee is using the requested items with benefit. The Plan denied your request. The Plan says rules for payment have not been met.

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 pay for a knee orthosis and a suspension sleeve. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's chief complaint was knee pain. The documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. There is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. Additionally, the item coded L2397 (sleeve) is not separately payable when the base item is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Furthermore, a suspension sleeve is not separately payable when the base item is not covered. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) and a suspension sleeve (L2397).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: skilled nursing facility, home with home health, and home physical therapy.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee admitted for weakness and falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medial necessary services could be provided in a low level of care. There is a not reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99211) provided by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you are appealing the denial regarding a COVID-19 test provided by someone you did not meet. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 the outpatient office visit (99211) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit (99213).

You asked the Plan to waive the copayment for the office visit. You say that you are appealing this decision because this was a televised visit and not an office visit. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.

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 copayment for in-network specialist's office services for Physician/Practitioner services, including doctor's office visits.

You have been asked to pay $15 copayment for in-network specialist's office services for the office visit. the office visit falls within the Physician/Practitioner services, including doctor's office visits 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 outpatient office visit (99213).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee orthosis (L1843).

You asked the Plan to pre-approve the knee orthosis. You say that this knee orthosis is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the request is not medically reasonable and necessary.

The Plan follows Medicare rules. Medicare rules say that the requested knee orthosis is subject to coverage criteria as listed in LCD L33318. 

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 knee orthosis. Our reviewer says that the enrollee does not meet Medicare criteria for this service. Our physician reviewer found the patient has not had a recent injury to or a surgical procedure on the knee. In addition, the patient is ambulatory but there is no objective evidence of knee instability or joint laxity on an exam.

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (L1843).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is on the
CMS Preclusion List.

The Plan must follow Medicare rules. Medicare rules say that unless and until an individual or entity is
reinstated into the Medicare, Medicaid, and other Federal health care programs in accordance with subpart F of
this part, no payment will be made by Medicare, including Medicare Advantage and Prescription Drug Plans,
Medicaid, or any other Federal health care program for any item or service furnished, on or after the effective
date specified in the notice.

We looked at the file and Medicare rules. The Plan has provided documentation from the CMS Preclusion List
showing that the provider in question was excluded with claim rejection. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the initial 15 minutes of deep sedation (D9222)
and the additional 15 minutes of deep sedation (D9223).

You asked the Plan to reimburse you for the dental services. You say that you have had 3 failed oral fistula
surgeries. You say that these 3 failed surgeries were painful and caused you great suffering. You say that you
could not handle this procedure without dental anesthesia. You say that you suffer from poor health issues and
emotional disabilities. You also say that you should be reimbursed for these services. The Plan denied your
request. The Plan says deep sedation services are not covered.

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, deep sedation is not among those
covered under this benefit. Additionally, the services you are asking the Plan to reimburse you 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. The record shows that you signed an
agreement acknowledging that the services would not be covered. Therefore, we decided that the Plan does not
have to reimburse you for the initial 15 minutes of deep sedation (D9222) and the additional 15 minutes of
deep sedation (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mental health sessions (90834, 99213).

You asked the Plan to waive the copayment for the mental health services. You say that you have a $0 copay on virtual mental health visits. The Plan denied your request. The Plan says individual therapy sessions are subject to a $25 copayment. The Plan states that the cost-share waiver for telehealth services was only valid.

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 $25 copayment for each individual mental health therapy session.

You have been asked to pay a $25 copayment for each individual mental health therapy session. The Plan's EOC has no mention of a separate cost-share amount for virtual mental health visits, and the cost-share waiver information was not included in this appeal. We cannot review the temporary cost-share waiver, but the Plan's contract clearly states that there is a $25 copayment for each individual mental health therapy session. 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 mental health sessions (90834, 99213).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have
not been met. The Plan says that the services needed could be provided in another setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been
denied. The documentation does not support that the enrollee in this case requires services at the LTACH that
are not available at the acute care hospital where he is currently receiving care. The documentation does not
support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case.
Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the
diagnosis and condition of the enrollee at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on September 16, 2020.
You asked the Plan to waive the copayment for ambulance transport. You say that you cannot afford to pay this bill. 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 $325 copayment for ambulance transport. You have been asked to pay $325 copayment for ambulance transport. 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 ambulance transportation provided on September 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services provided by a Certified Surgical Assistant (CSA) practitioner on October 5, 2020.
You asked the Plan to pay for surgical assistant services. You say that you had no idea who would be involved in your surgery and no way of knowing if they were Medicare participating staff. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is not eligible for Medicare coverage.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services provided by a Certified Surgical Assistant (CSA) practitioner on October 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Dual-energy X-ray absorptiometry (DXA) scan (77080) provided by an out of network (OON) provider.

You asked the Plan to pay for the DXA scan. You say that you had a referral. The Plan denied your request. The Plan says they do not cover services provided out of network, except in limited circumstances. This service was provided out of network, was not urgent, and no referral was submitted for review or 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. No referral was included in the record. 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 the Dual-energy X-ray absorptiometry (DXA) scan (77080) by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that an acute inpatient rehabilitation facility admission is
medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an
IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
fatigue and weakness. Your medical problems are stable. There are no complex nursing or rehabilitation needs.

You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. The medical record documents a need for physical and
occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be
provided at a low level of care.

There is a not reasonable expectation that you will be able to fully participate in and benefit from an intensive
rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug.

You asked the Plan to pay for the self-administered drug. You say that you feel that you should not be held responsible for the payment. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare Part B.

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 pay for the self-administered drug.

Benefits for the self-administered 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.