Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been 
met. 
 
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 and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan.

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, 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 continuous glucose monitor have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care services from August 24, 2021 and forward.
You asked the Plan to pre-approve SNF care services from August 24, 2021 and forward. You say that the requested SNF care is medically necessary. The Plan denied your request. The Plan says the requested SNF care 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 in the Medicare rules section 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 care services from August 24, 2021 and forward. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was recently admitted for chronic obstructive pulmonary disease (COPD) exacerbation. From a nursing perspective, the enrollee received oral and inhaled medications. The enrollee had stable vital signs. She had wound care to multiple areas. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a supervision/stand by assist level with functional mobility including gait to 120 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care services from August 24, 2021 and forward have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care services from August 24, 2021 and forward.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ultrasounds you had on June 24, 2019, and September 14, 2020.
You asked the Plan to waive the coinsurance for the ultrasounds. You say that you were not aware of these bills when you arranged a payment plan with the hospital. The Plan denied your request. The Plan says you were charged this coinsurance correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for outpatient diagnostic tests. You have been asked to pay 20% coinsurance for the ultrasounds. The ultrasounds fall 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 coinsurance for the ultrasounds you had on June 24, 2019, and September 14, 2020.
Your complaint about any adjustments to your payment plan is not a valid appeal for medical coverage. This
part of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services you received on May 14, 
2021. 
 
You asked the Plan to waive the copayment for the podiatry services. You say that this visit was just for toenail 
trimming, so you believe there should be no copayment. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that the medical records show this was not a routine visit. 

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 $40 
copayment for medically necessary foot care.  
 
You have been asked to pay a $40 copayment for the podiatry services. Medicare rules state that routine foot 
care is limited to a few services such as toenail trimming, callus removal, soaking the feet, and other 
evaluations when you have no signs or symptoms of medical problems.  Your medical records show that in 
addition to some of these routine services, your doctor also assessed you for tendonitis and recommended 
physical therapy for sciatica for you.  These services are beyond the scope of what is included with a routine 
visit.  That is why the podiatry services you received fall within the medically necessary foot 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 podiatry services you received on May 14, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an in-network exception to see an out-of-network endocrine surgery specialist.
You asked the Plan to pre-approve the in-network exception. You say that you would like to use the out-of-network provider. The Plan denied your request. The Plan says while your benefit covers out-of-network services, there are in-network provides available that can provide this service, therefore, the out-of-network rate would be applied.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that enrollees can use out-of-network providers, however unless there is a network deficiency, they will be assessed a higher cost-share. The Plan has network providers available who can provide the services at issue in this appeal. Therefore, we found no exception that would require the Plan to cover these out-of-network services at the in-network rate.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say additional PT is medically necessary. The Plan 
denied your request. The Plan says four (4) additional PT visits are not medically necessary.  
We decided that the Plan does not have to pre-approve four (4) additional PT visits. 
 
You asked the Plan to pre-approve additional PT visits. You say additional PT is medically necessary. The Plan 
denied your request. The Plan says four (4) additional PT visits are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 four (4) additional PT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally 
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health 
Plan. The enrollee has had extensive prior therapy visits and the records do not demonstrate that the unique 
skills of a professional therapist are required to safely and effectively provide treatment, that the services can 
be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The 
enrollee has been given additional therapy to ensure competence in a home exercise program. The requested 
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a 
qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of four (4) additional PT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve four (4) additional PT visits.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the copayment for the magnetic resonance imaging (MRI) spinal canal and contents (72141) the magnetic resonance imaging (MRI) any joint of upper extremity (73221) provided August 13, 2020 to September 23, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that your copay went up to $300 because it is coded as a hospital when it was at their clinic and they are charging you for two MRI's. This is not being sent to collections and appreciate help in this matter. The Plan denied your request. The Plan says that the claim was processed with the correct cost share 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 does not say in clear and accurate terms how much you should expect to pay for the diagnostic services. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
We looked at your contract with the Plan. The health plan contract says that there is a $75 - $300 copay for in-network provider's depending on the Medicare covered diagnostic radiology services for CT scans, MRI's, myelography, PET scans, MRA, SPECT, CTA, nuclear cardiology and stress tests. The Plan contract does not clearly say how much enrollees must pay for Outpatient diagnostic tests and therapeutic services and supplies. The plan needs to clearly indicate what you are supposed to pay for an MRI. The plan also did not provide an Explanation of Benefits (EOB) or any documentation for August 13, 2020 date of service. There was no claim or medical records provided to indicate where these services were rendered. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information and has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to waive the copayment for the magnetic resonance imaging (MRI) spinal canal and contents (72141) the magnetic resonance imaging (MRI) any joint of upper extremity (73221) provided August 13, 2020 to September 23, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the cervical spine provided on April 22, 2021.
You asked the Plan to waive the copayment for the MRI. You say that this cost sharing should be waived because it was related to coronavirus. The Plan denied your request. The Plan says this service was not billed with a coronavirus-related diagnosis, so this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $150 copayment for each advanced imaging service. The enrollee has been asked to pay a $150 copayment for the MRI. The MRI falls within the advanced imaging service benefit category. The records show that this MRI was ordered due to cervical disc displacement, not
anything related to the coronavirus. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the cervical spine provided on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you received on March 2, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you are appealing this copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this test ($109.71) is less than your copayment obligation, you are responsible for the full allowed 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 $110 copayment for diagnostic radiology services. 

You have been asked to pay a $110 copayment for the CT scan. The CT scan falls within the 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 the computed tomography (CT) scan of the chest you received on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 5, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you feel that this should be considered a home health visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialist services. 

The record shows that you received specialist services on April 5, 2021. The services you received do not fit the criteria for home health services. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 copayment for a specialist visit. A specialist 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 a specialist visit provided on April 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided to the enrollee on February 4, 
2021 and billed under code 60512. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correct ly. 
Providers must report services with the appropriate CPT code. We asked our coder 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 
this service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the operative 
report documents both procedures were performed through the same surgical approach or incision. If one or 
more of the parathyroid glands is re-implanted in the same surgical exposure, then it is not accurate to 
separately code 60512 based on Medicare billing guidelines. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for surgical services provided to the enrollee on February 4, 2021 and billed under code 60512.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional acupuncture visits for chronic low back pain.
You asked the Plan to pre-approve additional acupuncture visits. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have already received 30 acupuncture visits for the 2021 benefit year. The Plan says that you have exceeded this benefit limit for the calendar year.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the file shows that you have already received 30 acupuncture visits for the 2021 benefit year, which exceeds the benefit limit for these services. Therefore, we decided that the Plan does not have to pre-approve additional acupuncture visits for chronic low back pain.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.

You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the requested care does not constitute the skills of a licensed nurse.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our physician reviewer found that there is no documentation that the additional requested skilled nursing services are required to effectively provide services in order to improve your condition, or to perform a maintenance program to maintain your condition or prevent deterioration. Records document stable chronic conditions with no recent changes in status. The available medical records do not specify why the home health nursing services already provided are inadequate to meet the enrollee's needs. A note from the home health nurse indicates you are stable for discharge from services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the diagnostic colonoscopy you had at an ambulatory surgery center on December 22, 2020.

You asked the Plan to waive the cost sharing for the diagnostic colonoscopy. You say that you think you are being over charged for this service. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that when you received these services, you still had $111.39 remaining on your deductible. After the deductible was met, the Plan says that you were assessed the $100 copayment because your colonoscopy was diagnostic, not screening.

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 $100
copayment for each ambulatory surgery center visit after the deductible is met. 

You have been asked to pay a $100 copayment for the diagnostic colonoscopy in addition to the remaining $111.39 left of your deductible. The medical records from this colonoscopy show that it was not ordered as a screening, but rather it was ordered to evaluate your complaints of chronic constipation. That is why the copayment and the remainder of the deductible apply here. Diagnostic colonoscopies are considered outpatient surgery services. 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 sharing for the diagnostic colonoscopy you had at an ambulatory surgery center on December 22, 2020.