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

We decided that the Plan does not have to waive the copayment for the interpretation of external electrocardiographic recording provided on February 24, 2020.You asked the Plan to waive the copayment for the interpretation of external electrocardiographic recording. You say that you were charged for an office visit that you did not make on February 24, 2020. 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 each Medicare-covered diagnostic procedure and test for services in an in-network specialist's office. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $35 copayment for the interpretation of the external electrocardiographic recording.You have been asked to pay a $25.52 copayment for the interpretation of external electrocardiographic recording. The interpretation of external electrocardiographic recording falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the interpretation of external electrocardiographic recording is considered a remote diagnostic service.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the interpretation of external electrocardiographic recording provided on February 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you are now bruising when finger stick testing and have a hard time drawing blood. The Plan denied your request. The Plan says the record shows you do not test four or more times a day and are not insulin treated.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at this the file and Medicare rules. You are not insulin treated therefore you do not meet the Medicare coverage criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a participating provider on December 11, 2019.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have a copayment for a screening. 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 $275 copayment for outpatient surgery. You have been asked to pay a $275 copayment for a diagnostic colonoscopy. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed. A diagnostic colonoscopy falls within the outpatient surgery 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 diagnostic colonoscopy provided by a participating provider on December 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from August 17, 2020 to August 20, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that the claim was filed as out-of-network. You say the claim needs to be refiled and corrected. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day for days 1-5 at for Medicare-covered in-network inpatient hospital stays. The enrollee has been asked to pay a $300 copayment for each day of the inpatient stay. ($300 x 3 = $900). The inpatient stay falls within the "Inpatient hospital care" benefit category. The record shows that the claim was processed with the in-network benefit.
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 inpatient hospital stay provided from August 17, 2020 to August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says they do not meet the definition of a primary surgical dressing, and are not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that compression stockings are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enroll finds the finger sticks painful and difficult and control would be more optimal with a continuous glucose monitor. The Plan denied your request. The Plan says the enrollee does not meet the criteria per the LCD.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at review the file and Medicare rules. The enrollee is not insulin treated by injection three or more times a day so the Medicare coverage criteria for a CGM is not met. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmological services: medical examination and evaluation (92012) and ophthalmic ultrasound (76514) provided March 4, 2020.
You asked the Plan to waive the copayment for the vision services. You say that you went in for a routine eye exam which has a $0 copay and $150 coverage limit for routine eyewear. You never would have went for this appointment if you knew it was going to cost you. The Plan denied your request. The Plan says this correct copayment has been applied correctly per the plan benefits.
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 $45 for outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration and $45 for each Medicare covered x-ray for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay $57.32 for the vision and diagnostic services. The vision and diagnostic services falls within the outpatient diagnostic tests and therapeutic services and supplies and Vision care benefit categories. 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 ophthalmological services: medical examination and evaluation (92012) and ophthalmic ultrasound (76514) provided March 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 2, 2019 by a non-contracted provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 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 the medical services provided on May 2, 2019 by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy rendered on May 23, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 31625 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 31625 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites. We find that CPT code 31625 is not supported in the medical record. Specifically, there is no documentation of performance of a bronchoscopy. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the bronchoscopy rendered on May 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay forout of network chiropractic services provided on March 4, 2020.You asked the Plan to pay forout of network providers. You say that this service should be covered by the Plan.The Plan denied your request. The Plan says you did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that wouldrequire the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forout of network chiropractic services provided on March 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services rendered from December 1, 2019 to December 23, 2019.
You asked the Plan to waive the copayment for these services. You say that the enrollee is not liable for charges on days 1-20. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment for days 1-20 and a $160 copayment per day for days 21-47 for SNF care.
Review of the file shows that the enrollee received SNF services from December 1, 2019 to December 23, 2019. These days made up days 19 through 40 of the SNF benefit period. The file shows that the enrollee previously received SNF services from September 26, 2019 to November 30, 2019, making up days 1 through 18 of the benefit period. The enrollee has been asked to pay a $0 copayment for days 1-20 and a $160 copayment per day for days 21-40 for these services, for a total of $3,200. These services fall within the SNF care benefit category. 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 skilled nursing facility (SNF) services rendered from December 1, 2019 to December 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on January 20, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a respiratory panel, was requested solely for screening purposes. The file shows that the testing was not related to a respiratory diagnosis. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the respiratory panel rendered on January 20, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78815).
You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan denied your request. The Plan says that rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically 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 the PET scan. Our reviewer says that the PET scan is medically necessary. Our physician reviewer found the record shows the enrollee has an enlarging nodule suspicious for malignancy. PET scan is reasonable and necessary in this case for further evaluation. 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 PET scan have been met. Therefore, we decided that the Plan has to pre-approve a Positron Emission Tomography (PET) scan (78815).
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on January 31, 2020.
You asked the Plan to waive the copayment for an ambulance trip. You say that this was arranged by the nursing home. 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 $125 copayment for ambulance services. You have been asked to pay a $125 copayment for an ambulance trip. an ambulance trip falls within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 1, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat 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 physician's services providedon February 1, 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 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 the enrollee required moderate assistance with bed mobility and moderate assistance times two for transfers. The enrollee was swallowing independently. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care in an IRF. The enrollee's medical status with a hemoglobin of 6.9 on July 9, 2020 does not reveal the enrollee is medically stable to transfer to an IRF. The enrollee may benefit from further multiple therapies such as physical and occupational therapy, but the documentation does not support that the enrollee's functional level or endurance level can tolerate an 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.You asked the Plan to pre-approvethe compression stockings. You say that the compression stockings would help manage your edema.The Plan denied your request. The Plan says you do not have a qualifying wound.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6533 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over aqualifying wound.The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6533.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic chiropractic services provided from July 8, 2019 to December 9, 2019. You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the services provided are not covered by the Plan or by Medicare. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic chiropractic services provided from July 8, 2019 to December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need the requested incontinence pads due to your health issues. You say that you have trouble walking so it is difficult for you to move quickly to get to the restroom. You stated that you need supplies that will not leak because you are unable to make it to the restroom in a reasonable amount of time. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.