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

We decided that the Plan does not have to waive the copayment for the ECG provided on February 19, 2021.

You asked the Plan to waive the copayment for the ECG. You say that you already paid $150 for the procedure and received two other charges. You say that these are overcharges. The Plan denied your request. The Plan says the copayment for the ECG applied correctly. The Plan also says that the additional charges of $21.56 and $14.38 were removed.

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 $10 copayment for diagnostic lab services and diagnostic procedures and tests.

You have been asked to pay $8.21, which is less than the standard $10 copayment for the ECG. The ECG 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 copayment for the ECG provided on February 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve the inpatient psychiatric hospital services. You say that its not safe for the enrollee to leave the hospital. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of inpatient psychiatric services and could receive treatment at a less restrictive level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The patient was cooperative and compliant with medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift provided January 7, 2021.
You asked the Plan to pay for a stair lift. You say that you medical condition makes it dangerous to walk down stairs. The Plan denied your request. The Plan says a stair lift is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair lift provided January 7, 2021.
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 enrollee needs continued therapy post hospitalization to regain baseline function to ensure safety upon returning back home. You say that the enrollee needs intensive level therapy along with a multi-disciplinary approach to ensure that he can get back to his baseline level of function. You say that the enrollee will need medical oversight by a physician to manage his antibiotic therapy, wound care, uncontrolled blood sugars, and pain control. The Plan denied your request. The Plan says the guidelines for coverage of 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for gangrene and a below the knee amputation. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee 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. There is not a reasonable expectation that this enrollee 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (93306)
provided July 18, 2020.

You asked the Plan to waive the copayment for the diagnostic service. You say that this was processed
incorrectly. Please reprocess and correct with provider. The Plan denied your request. The Plan says this claim
was processed with the correct copayment 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 clearly says that you must pay $155
copayment for each Medicare covered radiological diagnostic service.

You have been asked to pay $155 copayment for the diagnostic service. The diagnostic service 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 copayment for the transthoracic echocardiography (93306) provided July 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory tests provided by an out-of-network provider on January 15, 2021.

You asked the Plan to pay for the laboratory tests. You say that the claim should be considered for payment and processed in accordance with the state prompt payment regulations. The Plan denied your request. The Plan says there is no authorization on file for the services rendered.

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 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 laboratory tests provided by an out-of-network provider on January 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on May 15, 2020.
You asked the Plan to pay for the therapeutic activities. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on May 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for deluxe frames (V2025), progressive lenses (V2781), and tint (V2745) received on February 27, 2021.
You asked the Plan to pay an additional amount for deluxe frames, progressive lenses, and tint. You say that you want the Plan to pay an additional amount towards the items. The Plan denied your request. The Plan says the benefit allowance of $100 was applied to the purchase.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $100 benefit maximum toward the purchase and fitting of eyeglasses per calendar year. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of deluxe frames, progressive lenses, and tint have not been met. Specifically, the record shows that you had exhausted your eyewear benefit maximum of $100 and are therefore, responsible for paying the remainder. Therefore, we decided that the Plan does not have to pay an additional amount for deluxe frames (V2025), progressive lenses (V2781), and tint (V2745) received on February 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of skin and tissue (11042) provided March 10, 2021.

You asked the Plan to waive the copayment for the removal of skin and tissue. You say that you were not aware you would be charged a copayment for these services. The Plan denied your request. The Plan says the cost share 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 $350 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities. 

You have been asked to pay a $350 copayment for the removal of skin and tissue. This service falls within the outpatient surgery and other medical services provided at hospital outpatient facilities 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 removal of skin and tissue (11042) provided March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an onabotulinumtoxina injection (J0585) provided on February 15, 2021.

You asked the Plan to waive the coinsurance for an injection. You say that you are only responsible for a copayment for this service. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for an injection. The allowed amount of the claim is $606, resulting in a coinsurance obligation of $121.20. The EOC confirms 20% is the required coinsurance for this service. An injection falls 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 coinsurance for an onabotulinumtoxina injection (J0585) provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a pneumatic appliance (E0673) provided on May 28, 2020.
You asked the Plan to pay for an intermittent limb compression device and a pneumatic appliance. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare to reduce the chances of deep vein thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and a pneumatic appliance (E0673) provided on May 28, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted special service (99199), and the home health aide or certified nurse assistant, providing care in the home, per hour, (S9122) provided on January 30, 2021.

You asked the Plan to pay for the home health services. You say that you are wheelchair bound after having emergency surgery. You say that you are covered for home health aide services, specifically speech therapy, occupational therapy, and skilled nursing. You also say that the services should be covered in your home too. The Plan denied your request. The Plan says the provider in this case is not certified for Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the unlisted special service (99199), and the home health aide or certified nurse assistant, providing care in the home, per hour, (S9122) provided on January 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam (D2150) provided on October 14, 2020.
You asked the Plan to pay for the dental service. You say that you were told that you were allowed 2 fillings per month at 50% off for your coverage. You say that your last 2 fillings were not covered, and you had to pay full price. You also say that you are on a limited income and cannot afford to pay this. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that there is no record that you contacted the plan to verify benefits and provider eligibility prior to the date of service.
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 and amalgam is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on September 9, 2020. Therefore, we decided that the Plan does not have to pay for the amalgam (D2150) provided on October 14, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
non-emergency transport, (A0428, A0425) provided June 18, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you don't understand why
you were charged the ambulance copayment. The Plan denied your request. The Plan says the copayment has
been applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for each one-way Medicare-covered ambulance trip.
You have been asked to pay a $150 copayment for the ambulance services. This service 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 the ambulance
service, basic life support, non-emergency transport, (A0428, A0425) provided June 18, 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 were independent before your hospitalization
and want to return to being independent. You say that you are eager to participate in the 3 hours of aggressive
rehab that an IRF will offer. You say that you do not have the support to safely discharge home at this time.
You say that you still require extensive hands-on assistance from the nursing and therapy staff at the hospital to
get out of bed. You say that your doctor has advised that you need closer medical management of your current
medical needs and disease to prevent being readmitted to the hospital. The Plan denied your request. The Plan
says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely
receive the services needed in another setting.

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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia and respiratory failure. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee 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. There is not a reasonable expectation that this enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a specialist provider office visit (99204) and a lumbar-sacral orthosis (L0650) provided on January 19, 2021.
You asked the Plan to waive the cost-sharing for a specialist visit and a lumbar-sacral orthosis. You say that you feel that the pain clinic should have provided thorough billing transparency. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for Medicare-covered durable medical equipment benefits. Your contract also says that you must pay a $20 copayment for services obtained from a specialist.
You have been asked to pay $123.72, or 20% of the Medicare-allowed charge of $618.61, for a lumbar-sacral orthosis. A lumbar-sacral orthosis falls within the "Durable Medical Equipment (DME) and Related Supplies" benefit category. You have also been asked to pay a $20 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 cost-sharing for a specialist provider office visit (99204) and a lumbar-sacral orthosis (L0650) provided on January 19, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from the provider 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.