Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facility fee provided on March 3, 2020.
You asked the Plan to waive the copayment for the facility fee. You say that you already paid your $35 copayment. You say you were never told you would have this fee and that you would not have gone for the visit. 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 $250 copayment for each day of Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the facility fee.
You have been asked to pay a $118.03 copayment for the facility fee. The facility fee falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the facility fee provided on March 3, 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 IRF level care is medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet IRF coverage criteria.
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 while the enrollee may benefit and participate in multiple therapies her functional
level does not require this on an intensive rehabilitation therapy program provided in an IRF. The enrollee's
needs can be met 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe refraction services (92015) provided February 25, 2020.You asked the Plan to pay forthe vision services. You say that in checking you were told they now charge for refraction procedure. Nothing changed from last year and you found no notice in the literature. The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation of once every12 months.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 these services when 1 routine eye exam every 12 months. We looked at the file and the Plan's rules. This service is covered once every 12 months. Records show that this service was provided August 13, 2019. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forthe refraction services (92015) provided February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on August 6, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for advanced imaging services. You have been asked to pay the allowed amount of $104.76, which is less than the $250 copayment for a CT scan. A CT scan 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 a CT scan provided on August 6, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on March 9, 2020.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
that the Plan requires utilization of network providers when possible and available, and requires authorization
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for diagnostic radiology services provided on March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder capacity measurement provided on February 24, 2020.You asked the Plan to waive the copayment for the bladder capacity measurement. You say that there was nosurgery. You say that this is the first time you've had a scan that wasn't completely covered.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 per date of service for an outpatient hospital facility.You have been asked to pay $265.10, which is less than the standard $350 copayment for the bladder capacity measurement. The bladder capacity measurement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe bladder capacity measurement provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on
December 13, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says that Original Medicare pays for Medicarecovered
non-hospice services provided by physicians, providers, or suppliers when the enrollee has elected the
Medicare hospice benefit.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on
December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laparoscopic cholecystectomy provided on October 9, 2018.You asked the Plan to waive the copayment forthe laparoscopic cholecystectomy. You say that you should not be responsible for the copayment. The Plandenied 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 $225 copayment for outpatient hospital surgery. You have been asked to pay a $225 copayment for the laparoscopy. The laparoscopy 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 forthe laparoscopic cholecystectomy provided on October 9, 2018.Your complaint about the late billing is not a valid appeal for medical coverage. Your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on December 28, 2019.
You asked the Plan to pay for the ambulance service and ground mileage. You say that this was an emergent run from the enrollee's residence to the hospital. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ambulance service and ground mileage provided on December 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethepercutaneous nerve stimulator.You asked the Plan to pre-approve the percutaneous nerve stimulator. You say that the enrollee needs the percutaneous nerve stimulator for chronic intractable pain.The Plan denied your request. The Plan says this device is not a Medicare covered benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. This type of device is non-covered by Medicare. The FDA approval for this device was approved as substantially equivalent to the NSS-2 Bridge device therefore it is also noncovered. Based on this information, we decided that Medicare rules for coverage of the percutaneous nerve stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve the requested percutaneous nerve stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 surgical extractions (D7210) to be provided by an oral surgeon.You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain and need to have the teeth removed because they are broken and infected.The Plan denied your request. The Plan says services must be performed by a participating general dentist therefore, dental services provided by an oral surgeon is 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve 2 surgical extractions (D7210) to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay provided from January 6, 2020 to January 9, 2020.You asked the Plan to waive the coinsurance for the inpatient hospital stay. You say that you should not be responsible for the $2,195.54 amount. 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 20% coinsurance for each in-network Medicare-covered hospital stay. You have been asked to pay $2,195.54 which is less than 20% of the allowed amount for the inpatient hospital stay. The allowed amount is $11,361.33. ($11,361.33 x 20% = $2,272.27). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows you are being charged less than the standard amount because you met your maximum out-of-pocket amount.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 inpatient hospital stay provided from January 6, 2020 to January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve9 months of Xolair (J2357) in addition to the 3 months already approved by the plan.You asked the Plan to pre-approve9 more months of Xolair. You say that Xolair is medically necessary.The Plan denied your request. The Plan says there is not yet sufficient documentation to support 9 months of additional treatment.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 9 more months of Xolair. Our reviewer says that 9 months of injections are not medically necessary at this time. Our physician reviewer found the new health plan approved 3 months of Xolair to allow continuity and so records could be obtained by the health plan. Without medical records to support the necessity and effectiveness of Xolair for this patient, an additional 9 months is not medically necessary.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 more months of Xolair have not been met.Therefore, we decided that the Plan does not have to pre-approve9 months ofXolair (J2357) in addition to the 3 months already approved by the plan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the SPECT test provided on February 4, 2020.
You asked the Plan to waive the coinsurance for the SPECT test. You say that no one told you that would be a copayment for such a minor procedure. 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 20% coinsurance for each nuclear (cardiac and non-cardiac) medicine study or imaging. You have been asked to pay $67.10 which is 20% of the allowed amount for the SPECT test. The allowed amount is $335.52. ($335.52 x 20% = $67.10). The SPECT test 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 coinsurance for the SPECT test provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a blood pressure cuff.
You asked the Plan to pre-approve the blood pressure cuff. You say that the blood pressure cuff is medically necessary. The Plan denied your request. The Plan says a blood pressure cuff is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a blood pressure cuff.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral supplies provided from March 7, 2020 to March 13, 2020.You asked the Plan to pay for the enteral supplies. You say that that the Plan should pay this claim.The Plan denied your request. The Plan says that this claim cannot be paid separately based on Medicare guidelines for inpatient services.The Plan must follow Medicare rules. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an enrollee.The facility must furnish all necessary covered supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies would have been included in the global payment submitted to the plan by the facility. If the health plan is not covering the SNF stay, the cost of these supplies is absorbed by the facility.Therefore, we decided that the Plan does not have to pay for the enteral supplies provided from March 7, 2020 to March13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning pillow (E0190).
You asked the Plan to pre-approve the pillow. You say that the pillow is medically necessary. The Plan denied
your request. The Plan says a positioning pillow is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a positioning pillow (E0190).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administer drugs provided from January 18, 2020 to
January 20, 2020.
You asked the Plan to pay for the self-administer drugs. You say that you were not allowed to use your own
drugs from home. The Plan denied your request. The Plan says these drugs are not covered under your
Medicare Part B benefit.
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 pay for the self-administer drugs
provided from January 18, 2020 to January 20, 2020.
Benefits for the self-administer drugs 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: 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 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is
mostly standby assist to minimal assist for functional transfers and activities of daily living (ADL's) and a less
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and
predicted period. An IRF intensity is not warranted.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positioning cushion (E0190).
You asked the Plan to pre-approve the positioning cushion. You say that you need the pillow for treatment of
GERD. The Plan denied your request. The Plan says the pillow is not a medical device and the item was not
prescribed or ordered by a physician.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a positioning cushion (E0190).