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

We decided that the Plan does not have to waive the deductible for a venography provided an out-of-network provider on February 20, 2020.You asked the Plan to waive the deductible for a venography. You say that theseservices were approved. The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that the correct deductible amount has been charged.The rules say a plan must disclose to its enrollees in clear, accurate terms all costsharing information. Your contract with the Plan says that there is a $950 deductible for outpatient diagnostic tests/out-of-network. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests/out-of-network. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $573.41 deductible for outpatient diagnostic tests/out-of-network. This cost sharing is a contractual obligation that had not been met at the time a venography was received on February 20, 2020. Therefore, we decided that the Plan does not have to waive the deductible for a venography provided by an out-of-network provider on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Life Alert device (A9280).
You asked the Plan to pre-approve the Life Alert device. You say that the entire treatment team has recommended that the medical Life Alert is medically necessary. You consider it critical to provide immediate help when a fall occurs. The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.
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 the Life Alert device (A9280).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 currently undergoing treatment at an acute care hospital for a hip fracture in the setting of known metastatic lung cancer. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. The enrollee can remain at the current acute care hospital until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on March 3, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you were told to go to the emergency room due to blood work results. You say nothing was wrong with your blood work and would like the copayment removed. 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 $90 copayment for each Medicare-covered emergency room visit in-and out-of-service area. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received services at your emergency room 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 waive the copayment forthe emergency room visit provided on March 3, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement procedures (11042) and a
specialist office visit (99213) provided from February 4, 2020 to March 12, 2020.
You asked the Plan to waive the copayment for debridement procedures and a specialist office visit. You say
that you never had any services you would consider surgery. The Plan denied your request. The Plan says these
services 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 $225
copayment for outpatient surgery services and a $50 copayment for each visit with a specialist.
You have been asked to pay $225 for each debridement procedure, which is considered a surgical service, and
$50 a specialist office 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 waive the copayment for debridement procedures
(11042) and a specialist office visit (99213) provided from February 4, 2020 to March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care provided by a participating
provider on January 14, 2020.
You asked the Plan to waive the copayment for wound care. You say that you do not believe that wound care is
an outpatient surgery. 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 $350
copayment for outpatient surgery/Preferred/outpatient hospital facility.
You have been asked to pay a $350 copayment for wound care. Wound care falls within the outpatient
surgery/Preferred/outpatient hospital facility 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 wound care provided by a participating provider on January 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forIV start (A0999) and pulse oximetry (A0999) provided January 27, 2020.You asked the Plan to pay forthe ambulance supplies. You say that you only received one ambulance service not two and feel that these items denied in error.The Plan denied your request. The Plan says payment for these items is included in the payment for the ambulance transport.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. Oxygen and other items and services provided as part of the transport are included in the fee schedule base payment rate and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the ambulance supplies have not been met.Therefore, we decided that the Plan does not have to pay forIV start (A0999) and pulse oximetry (A0999) provided January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the wound debridement services provided
from January 7, 2020 to March 13, 2020.
You asked the Plan to reduce the copayment for the wound debridement services. You say that your copayment
was always $125 a visit and now it is $175 a 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 $175
copayment for each Medicare-covered in-network outpatient facility visit.
You have been asked to pay a $175 copayment for the wound debridement services on each date of service.
The wound debridement services fall 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 reduce the
copayment for the wound debridement services provided from January 7, 2020 to March 13, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 3 power wheelchair and accessories.You asked the Plan to providea Group 3 power wheelchair and accessories. You say that you need a Group 3 power wheelchair and accessories.The Plan denied your request. The Plan says you do not have a mobility limitation due to a condition listed.The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to:1. A neurological condition;2. Myopathy; or3. Congenital skeletal deformity.The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity.Therefore, we decided that the Plan does not have to providea Group 3 power wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture provided on September 25, 2019.
You asked the Plan to pay for the cone beam CT capture. You say that the x-ray is fully covered under your dental insurance. You say that you are requesting the $91 that you paid for the x-ray. The Plan denied your request. The Plan says the service is not a covered benefit.
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 cone beam CT capture provided on September 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that a SNF is medically necessary and appropriate.The Plan denied your request. The Plan says the enrollee does not meet the criteria for a SNF admission.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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of askilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have complex wound care or other ongoing SNF level skilled nursing needs. His functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you required minimal assistance for transfers and walking 80 feet. You required
minimal to moderate assistance for bed mobility. The documentation does not support that you require
supervision by a physical medicine and rehabilitation Physician or need acute rehab nursing care. The
documentation does not support that you require an interdisciplinary approach to rehabilitation care. While you
may benefit from further physical and occupational therapy, you do not require an intensive rehabilitation
therapy program.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy rendered from November 20, 2019 to December 13, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe home infusiontherapy rendered from November 20, 2019 to December 13, 2019.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on February 27, 2020 by an out of network (OON) provider.You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for pain management services provided on February 27, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport provided on September 17, 2019.
You asked the Plan to pay for the ambulance transport to dialysis. You say that the transport was medically
necessary. The Plan denied your request. The Plan says the enrollee could have been transported by another
type of vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 the ambulance transport to dialysis. Our
reviewer says that the service was not medically necessary. Our physician reviewer found the enrollee was
transported between a skilled nursing facility and a dialysis center. The enrollee was noted to be ambulatory
using a rolling walker. Documentation does not support the enrollee was unable to sit safely or outline why
alternate modes of transport were not considered. Without the support of the documentation, Medicare criteria
were not met. The denial is upheld.
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 ambulance transport to dialysis have not been met. Therefore, we decided
that the Plan does not have to pay for the ambulance transport provided on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit and the Part B injections provided on January 31, 2020 and February 24, 2020.You asked the Plan to waive the cost share for the specialist office visit and the Part B injections. You say that that your old plan did not charge any additional amounts during office visits. You say you should only have a $35 copayment for office visits. 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 $35 copayment for in-network physician specialist services and 20% coinsurance for all other in-network drugs covered under Medicare Part B. You have been asked to pay a $35 copayment for the specialist office visit on January 31, 2020. You have also been asked to pay $14.40 which is 20% of the allowed amount for the Part B injections on January 31, 2020 and February 24, 2020. The allowed amount is $71.95. ($71.95 x 20% = $14.40). The total amount you owe is $63.80. ($35 + $14.40 + $14.40). The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B injections 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 specialist office visit and the Part B injections provided on January 31, 2020 and February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cataract surgery provided on March 3, 2020.You asked the Plan to waive the copayment forthe cataract surgery. You say that that Medicare paid their part and now the Plan has to pay for their part of the bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say aplan 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 surgery services at an in-network outpatient hospital. You have been asked to pay a $250 copayment for the cataract surgery. The cataract surgery 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 towaive the copayment forthe cataract surgery provided on March 3, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had stable vital signs. The enrollee required minimal assistance with functional mobility including walking to 80 feet with a rolling walker. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).