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

We decided that the Plan does not have to waive the deductible and the copayment for the echocardiogram and the specialist office visit provided from November 12, 2020, to November 18, 2020.

You asked the Plan to waive the deductible and the copayment for the echocardiogram and the specialist office visit. You say that you expected that the services would be covered by your insurance. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

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 that applies towards echocardiograms, a $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in an in-network physician's office or at a free-standing facility (such as a radiology center or medical clinic), and a $35 copayment for services obtained from an in-network specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules). 

The echocardiogram you asked the Plan to waive the deductible and the copayment for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The specialist office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards the echocardiogram. See chart below.

Date of Service
Service
Allowed Amount
Deductible/
Copayment
Member Liability

November 12, 2020
Echocardiogram
$464.27
$750
$453.96 - You met your $750 deductible with this amount.

Echocardiogram
$10.31 - This is the remaining allowed amount after the deductible was applied. ($464.27 - $453.96)
$160
$10.31

November 18, 2020
Specialist office visit
$50.62
$35
$35

Total
$499.27
This cost sharing is a contractual obligation that had not been met at the time the echocardiogram and the specialist office visit were received on November 12, 2020 to November 18, 2020. Therefore, we decided that the Plan does not have to waive the deductible and the copayment for the echocardiogram and the specialist office visit provided from November 12, 2020, to November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on January 25, 2021.
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you met your out-of-pocket maximum for 2020. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for durable medical equipment.
You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $6,301.02. The total amount you are being asked to pay is $1,260.20 ($6,301.02 x 20% = $1,260.20). Durable medical equipment cannot be charged until the equipment is picked up; therefore, this coinsurance has been applied correctly to your 2021 out-of-pocket maximum. Durable medical equipment falls within the durable medical equipment 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 durable medical equipment provided by a participating provider January 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 29, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the proper POS code. 

We looked at the file and Medicare rules. The file shows that the services at issue were billed with Place of Service (POS) code 15 for a mobile unit. This POS code is not appropriate for these services. 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 testing services rendered on October 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses.

You asked the Plan to pre-approve eyeglasses. You say that you need the new eyeglasses. The Plan denied your
request. The Plan says you last received eyeglasses on December 31, 2019. The Plan says that you are covered
for eyeglasses every two years and are not eligible until December 31, 2021, for a new pair of eyeglasses.
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 every two years.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of eyeglasses have not been met. The file shows that you last received eyeglass on December 31,
2019, and you are not eligible for new eyeglasses until December 31, 2021. Therefore, we decided that the Plan
does not have to pre-approve eyeglasses.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on November 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that this service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 work provided on November 4, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for eye examinations provided from August 24, 2020, to November 16, 2020.

You asked the Plan to waive the copayments for eye exams. You say that you cannot pay these copayments, and your vision has not been helped. The Plan denied your request. The Plan says the copayment amounts you are being charged are 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 $45 copayment for each eye exam. There were 3 eye exams, resulting in a total copayment amount of $135. 

You have been asked to pay $45 copayment for each eye exam. Eye exams fall within the Vision 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 copayments for eye examinations provided from August 24, 2020, to November 16, 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 need IRF services to get your strength back to move around on your own. The Plan denied your request. The Plan says you do not meet the requirements for an IRF admission.
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 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. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2021, to February 16, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 18, 2021, to February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Fluid Flow/Fluid GF.

You asked the Plan to pre-approve Fluid Flow. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because Fluid
Flow is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are 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 Fluid Flow. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has lower back and knee pain. The use of stem cells for this indication is not
established as a proven therapeutic in medical literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Fluid Flow have not been met. Therefore, we decided that the Plan does not
have to pre-approve use of Fluid Flow/Fluid GF.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for biofeedback training (90901) provided October 23, 2020, to December 30, 2020.

You asked the Plan to pay for biofeedback training. You say that these services are medically necessary to build your immune system. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that biofeedback therapy is only covered for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, cold, massage, exercise, support) have not been successful.

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 biofeedback therapy. Our reviewer says that the criteria for biofeedback therapy have not been met. Our physician reviewer found that the provided documentation does not clearly show that you have a specific area of muscle spasm/weakness/spasticity that has failed conservative treatments to be able to meet criteria for biofeedback therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of biofeedback training have not been met. Therefore, we decided that the Plan does not have to pay for biofeedback training (90901) provided October 23, 2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.

You asked the Plan to pre-approve the services. You say that you have sent the treatment authorization request form and the pertinent clinical documents. The Plan denied your request. The Plan says this cannot be covered for a diagnosis of headache.

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 diagnosis for this request is a headache. This type of service is only covered for manual manipulation of the spine to correct a subluxation. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus VDZ testing provided to the enrollee on December 7, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this testing is experimental.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the case file contains insufficient records to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Prometheus VDZ testing provided to the enrollee on December 7, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the additional copayment for an X-ray provided on January 12, 2021.
You asked the Plan to waive the additional copayment for an X-ray. You say that you should not owe a separate copayment for the same service provided on the same day. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $20 copayment for X-rays. If the same service type is performed at the same session, more than once, only one copayment will be applied. The Plan says you must pay a $20 copayment for each X-ray. Based on the Plan contract, however, you cannot be asked to pay more than one $20 copayment for X-rays provided on the same day. Therefore, we decided that the Plan has to waive the additional copayment for an X-ray provided on January 12, 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography (PET) scan.
You asked the Plan to pre-approve AQMBF-PET scan. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this PET scan is not medically necessary.
The Plan follows Medicare rules. Medicare rules state that a PET scan may be covered under circumstances, including when it is used in place of a SPECT scan. 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 AQMBF-PET scan. Our reviewer says that the enrollee meets the Medicare criteria for the requested AQMBF-PET scan. Our physician reviewer found the enrollee has known ischemic heart disease and symptoms. He is morbidly obese and notes a possible complication with a prior single photon emission computed tomography (SPECT) scan. PET scanning in this situation is covered in lieu of SPECT imaging. It is also medically reasonable and necessary in this specific clinical situation to assess for ischemia in a symptomatic patient with a history of coronary artery bypass graft surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of AQMBF-PET scan have been met. Therefore, we decided that the Plan has to pre-approve an absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography (PET) scan.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug infusions provided on January 14, 2020.

You asked the Plan to waive the coinsurance for Medicare Part B drug infusions. You say that you were not told that you would owe 20% coinsurance for Medicare Part B drugs and would not have received the services had you known. 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.

You received Medicare Part B drug infusions on January 14, 2020. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $12,725.38 and 20% of that is $2,545.08

You have been asked to pay the total coinsurance amount of $2,545.08 for Medicare Part B drug infusions.

Medicare Part B drug infusions fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drug infusions provided on January 14, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to waive the coinsurance for an X-ray provided on January 7, 2021.

You asked the Plan to waive the coinsurance for an X-ray. You say that you do not understand why the charges were not covered. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 co-payment for basic radiology services.

The Plan says you must pay 20% coinsurance for an X-ray. Based on the Plan contract, however, you cannot be asked to pay more than a $0 co-payment for an X-ray. Therefore, we decided that the Plan has to waive the coinsurance for an X-ray provided on January 7, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you recently had surgery
and need additional transportation to go to appointments. The Plan denied your request. The Plan says your
transportation benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.