Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services provided on March 8, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the Plan denied payment for the Guardant Health testing due to the
diagnosis code that was used to bill for the services. However, the Plan provided no Medicare guidelines
showing why the diagnosis code that was billed is unacceptable or what diagnosis code the Plan would have
paid. We find that the Plan has not substantiated their reasoning for denial of payment. Therefore, we decided
that the Plan has to pay for the laboratory services provided on March 8, 2021.

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: 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the patient was admitted for a lung infection and pleural effusion after recent cardiac surgery. Medical conditions are stable.

There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient 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. In conclusion, there is not a reasonable expectation that this patient 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the limited ultrasound scan of 1 breast (76642) provided March 24, 2021.

You asked the Plan to waive the cost share for the limited ultrasound scan of 1 breast. You say that you believe this service should be related to the coronavirus exam and not classified as a diagnostic breast exam. The Plan denied your request. The Plan says the claim has processed correctly at this time.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. 

The item or service you asked the Plan to waive the cost share for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the limited ultrasound scan of 1 breast was received on March 24, 2021.

In addition, the medical records do not indicate this was related to a positive coronavirus test but was instead a diagnostic exam based on a previous screening mammogram. Therefore, we decided that the Plan does not have to waive the cost share for the limited ultrasound scan of 1 breast (76642) provided March 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable venous access device (36591) performed on May 7, 2020.
You asked the Plan to waive the copayment for a collection of a blood specimen from an implantable venous access device. You say that you have never before had to pay a copayment for blood draws. The Plan denied your request. The Plan says that the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for laboratory tests. The Plan says you must pay a $110.73 copayment for a collection of blood specimen from an implantable venous access device. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for a collection of blood specimen from an implantable venous access device. Therefore, we decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable venous access device (36591) performed on May 7, 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: 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 service is medically necessary. The Plan denied your request. The Plan says the service 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 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 your medical conditions are stable and you have no complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 pay for the acute inpatient hospital admission.

You asked the Plan to pay for acute inpatient hospital admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case.

Our physician reviewer found the record indicates that the enrollee is scheduled for a total knee arthroplasty. The record does not indicate a reasonable expectation of a length of stay spanning two or more midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital admission have not been met. Specifically, medically necessary services can be obtained in observational level of care. This means admission into acute inpatient hospital is not medically necessary. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the continuous positive airway pressure (CPAP) device provided January 17, 2021, to May 17, 2021.

You asked the Plan to waive the copayment for the CPAP device. You say that you believed that this equipment would be covered in full. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.

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 durable medical equipment and related supplies. 

You have been asked to pay a 20% coinsurance for the CPAP device. Although your previous cost share in 2020 was $0, this cost share changed in 2021 for durable medical equipment in 2021.

This device falls within the durable medical equipment and related 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 continuous positive airway pressure (CPAP) device provided January 17, 2021, to May 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 30, 2021, to February 1, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you did not take any pills that were not prescribed by a doctor. You also say that you are wondering if the additional 30mg of Isosorbide Mononitrate on top of the original 60mg prescription you had is the problem. The Plan denied your request. The Plan says the drugs received are not Part B covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided from January 30, 2021, to February 1, 2021.

Benefits for the self-administered 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental crown procedure provided on March 30, 2021.
You asked the Plan to pay for the dental crown procedure (D2920). You say that you were not aware of the deductible and will not pay the bill. The Plan denied your request. The Plan says the deductible is only waived for diagnostic and preventive services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $100 deductible for dental services. The item or service you asked the Plan to pay for falls within the benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $100 deductible for dental services other than diagnostic or preventive services. This cost sharing is a contractual obligation that had not been met at the time the dental crown procedure (D2920) was received on March 30, 2021. Therefore, we decided that the Plan does not have to pay for the dental crown procedure provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on April 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were provided prior to obtaining authorization to avoid delay in care. The Plan denied your request. The Plan says there were 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the wound care services provided on April 5, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable venous access device (36591) performed on May 22, 2020.

You asked the Plan to waive the copayment for a collection of a blood specimen from an implantable venous access device. You say that you have never before had to pay a copayment for blood draws. The Plan denied your request. The Plan says that the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for laboratory tests. 

The Plan says you must pay a $110.73 copayment for a collection of a blood specimen from an implantable venous access device. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for a collection of a blood specimen from an implantable venous access device. Therefore, we decided that the Plan has to waive the copayment for a collection of a blood specimen from an implantable venous access device (36591) performed on May 22, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80061, 82947, 84460) rendered by the OON provider on March 3, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.

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 the laboratory services (80061, 82947, 84460) rendered by the OON provider on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on March 6, 2021.

You asked the Plan to pay for the provided item. You say that where there is a conflict, Medicare sources will apply. The Plan denied your request. The Plan says medical records document no insulin.

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. In this case, there is no documentation that indicates the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, requires frequent self-adjustment of insulin dosage based on the blood glucose testing results, and had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the provided item have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on March 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs and does not have to waive the copayment for a CT scan provided from April 28, 2020, to May 15, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drugs and to waive the copayment for a CT scan. You say that you met the met the MOOP amount and deductible prior to receiving the services and should not be responsible for 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 the MOOP amount for 2020 is $3,300. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay an $80 copayment for CT scans. 

You received Medicare Part B drugs on April 28, 2020. The record shows that you had only paid $1,313.10 toward the $3,300 MOOP prior to receiving the services. Therefore, you are responsible to pay your share of the costs-sharing charges. The total allowed amount for the Medicare Part B drugs is $866.63 and 20% of that is $173.33. 

You received Medicare Part B drugs on April 29, 2020. The record shows that you had only paid $1,486.43 toward the $3,300 MOOP prior to receiving the services. Therefore, you are responsible to pay your share of the costs-sharing charges. The total allowed amount for the Medicare Part B drugs is $3,919.98 and 20% of that is $784. 

You received a CT scan on May 15, 2020. The record shows that you had only paid $2,831.61 toward the $3,300 MOOP prior to receiving the services. Therefore, you are responsible to pay the $80 copayment. 

The total amount you owe is: $1,037.33. 

You have been asked to pay the total amount of $1,037.33 for Medicare Part B drugs and a CT scan. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. A CT scan 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 Medicare Part B drugs and does not have to waive the copayment for a CT scan provided from April 28, 2020, to May 15, 2020.
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 the service is medically necessary. The Plan denied your request. The Plan says the service 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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where currently receiving 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 the LTACH services have not been met. Specifically, medically necessary services are being provided at the enrollee's current level of care.

This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not
have to pre-approve long term acute care hospital (LTACH) services.