Persius/hicric huggingface dataset:
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 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 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 there are no services at the LTACH that the enrollee requires that are not already
available and covered at the current facility. Therefore, this request for LTACH services will be considered not
medically necessary. Transfer to a lower level of care may be considered when treatment has completed.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the home health services provided from October 23, 2020, to December 19, 2020.

You asked the Plan to waive the cost share for the services provided. You say that you cannot pay the bill. The Plan denied your request. The Plan says the claim was processed 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 50% coinsurance for out-of-network home health agency care. 

You have been asked to pay a 50% coinsurance for the out-of-network services provided. The services fall within the home health agency 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 cost share for the home health services provided from October 23, 2020, to December 19, 2020.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation
that this 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 13,
2020, to May 21, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should not owe
anything on this claim. 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 $275
copayment per day, for days 1-6 for inpatient hospital care. Your contract with the Plan also clearly says that
you pay $0 for days 7-90 for inpatient hospital care.
You have been asked to pay a $275 copayment per day for inpatient hospital care. The records show that you
were inpatient for eight (8) days and only charged for six (6) days ($275 x 6 days = $1,650). The EOC confirms
$275 per day is the required copayment for this service. 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 May 13, 2020, to May 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening (81185, 81401, 81404, 81405, 81406, 81479) provided on October 26, 2020.
You asked the Plan to pay for hereditary cardiovascular screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening (81185, 81401, 81404, 81405, 81406, 81479) provided on October 26, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the frames and lens package (FRLNA), deluxe frames (V2025) and sphere, single vision lenses (V2100) provided November 16, 2021.

You asked the Plan to provide additional payment for the frames and lenses. You say that you are frustrated with your vision vendor. The Plan denied your request. The Plan says the maximum allowance for routine eyewear purchased from a non-participating provider has been issued and no additional reimbursement is due.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eyewear purchased from a non-participating provider up to $90 per calendar year. 

We looked at the file and the Plan's rules. In this case you purchased routine eyewear from a non-participating provider. The Plan has provided documentation showing that the full $90 allowance has been applied to your claim. Based on this information, we decided that the Plan does not have to provide additional payment for the frames and lens package (FRLNA), deluxe frames (V2025) and sphere, single vision lenses (V2100) provided November 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries study provided on January 26, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the duplex scan of extracranial arteries study. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 duplex scan of extracranial arteries study provided on January 26, 2021 by an out of network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic exam, esophagus (74220) provided March 16, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you are requesting the copay to be waived. Your doctor referred you to this facility as the imaging was not available at their clinic and feel you shouldn't have to pay. The Plan denied your request. The Plan says the claim was processed with the correct copayment 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 $150 copay for x-rays and ultrasounds at an outpatient hospital setting. 

You have been asked to pay $150 copay for the diagnostic service. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the radiologic exam, esophagus (74220) provided March 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the computed tomography (CT) scan provided on March 8, 2021.

You asked the Plan to waive the copay for the CT scan. You say that the copay should be waived. The Plan denied your request. The Plan says you are responsible for the copay.

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 copay per day for diagnostic radiology services.

You have been asked to pay $267.04 for the CT scan. Because the amount is less than the $325 copay, you were charged the lesser amount. The CT scan falls within the outpatient 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 copay for the computed tomography (CT) scan provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytogenetics and molecular cytogenetics services coded 88291 provided on February 12, 2021.

You asked the Plan to pay for the cytogenetics and molecular cytogenetics services. 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 88291 is cytogenetics and molecular cytogenetics, interpretation and report. 

In this case, this claim cannot be paid as billed due to the associated diagnosis code relationship criteria not being met. This code was billed with diagnosis code C91.10 (Chronic lymphocytic leukemia of B-cell type not having achieved remission). This is not an appropriate diagnosis code to be billed for this code. Based on this information, we decided that Medicare rules for coverage of the cytogenetics and molecular cytogenetics services have not been met. Therefore, we decided that the Plan does not have to pay for the cytogenetics and molecular cytogenetics services coded 88291 provided on February 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 8, 2021, to January 10, 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 SNF care beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from January 6, 2020, to November 7, 2020. The Plan has covered 100 days of SNF care. 

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 8, 2021, to January 10, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the incision and drainage of abscess services coded 10061 provided on December 10, 2020.
You asked the Plan to pay for the incision and drainage of abscess services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 10061 is incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple.
We find that CPT code 10061 is not supported in the medical record. Specifically, the documentation submitted
did not include documentation to support a complicated or that multiple incisions and drainage of abscess (e.g,
carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia) was
performed. Based on this information, we decided that Medicare rules for coverage of the incision and drainage
of abscess services have not been met. Therefore, we decided that the Plan does not have to pay for the incision
and drainage of abscess services coded 10061 provided on December 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Kanjinti injection rendered on February 15, 2021.

You asked the Plan to waive the coinsurance for these services. You say that you have met your maximum out of pocket. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B covered chemotherapy drugs and other Part B covered drugs.

Review of the file shows that you received a Kanjinti injection on February 15, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B covered chemotherapy drugs and other Part B covered 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.

The file shows that you reached your maximum out of pocket amount with the processing of this claim. The Plan applied a total of $171.24 for the coinsurance. Therefore, we decided that the Plan does not have to waive the coinsurance for the Kanjinti injection rendered on February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry services you had on January 27, 2021.

You asked the Plan to waive the copayment for the podiatry services. You say that you only had a toenail trimming and you have never been charged for that in the past. The Plan denied your request. The Plan says the medical records show you received more than a nail trimming at this visit, so the copayment 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 $15 copayment for podiatry services.

You have been asked to pay a $15 copayment for the podiatry services. Records from this visit show that in addition to nail trimming, your doctor reviewed your foot deformity and recommended custom foot orthotics to slow down the progression of the deformity. 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 podiatry services you had on January 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the positron-emission tomography (PET) imaging provided on December 16, 2020, billed with diagnosis code D47.9.

You asked the Plan to pay for the PET scan interpretation as billed. You say that the records provided support this imaging was medically necessary. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan interpretation as billed have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the positron-emission tomography (PET) imaging provided on December 16, 2020, billed with diagnosis code D47.9.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient services provided from March 2,
2021, to March 4, 2021.
You asked the Plan to waive the copayment for the inpatient services. You say that you would like the Plan to
waive your coinsurance. The Plan denied your request. The Plan says you were charged less than the enrollee
responsibility.
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 $295
copayment per day, days 1-7 for Inpatient Hospital Care.
You have been asked to pay a $261.46 copayment per day, days 1-7 for the inpatient services. The inpatient
services fall 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 services provided from March 2, 2021, to March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Decipher Prostate Cancer Classifier assay provided on January 11, 2021.

You asked the Plan to pay for the Decipher Prostate Cancer Classifier assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The Decipher Prostate Cancer Classifier assay at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Decipher Prostate Cancer Classifier assay provided on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on January 5, 2021.
You asked the Plan to waive the copayment for an MRI. You say that you do not agree with this copayment. 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 a $325 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay $273.14 which is less than your copayment amount of $325 for an MRI. The correct copayment has been applied to the services that were provided. An MRI falls within the outpatient diagnostic tests/diagnostic radiology 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 an MRI provided by a participating provider on January 5, 2021.