Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient hospital services.

You asked the Plan to waive the copay for the services provided. You say that you are being overcharged. The Plan denied your request. The Plan says the copay 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 $250 copay per day for days 1-7 for inpatient hospital care.

You have been asked to pay a $250 copay per day, totaling $500 for the services provided. The services fall within the inpatient hospital 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 copay for the inpatient hospital services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient stay provided from December 10, 2020, to December 14, 2020.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you were never admitted as an inpatient. You say you told you were "not in the hospital" but considered emergency overflow. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $360 copayment per day for days 1 through 5 for covered in-network hospital care. You have been asked to pay a $1,440 copayment for the inpatient hospital stay. ($360 x 4 days = $1,440). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The medical record shows you were admitted as an inpatient. 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 reduce the copayment for the inpatient stay provided from December 10, 2020, to December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to waive the coinsurance a continuous passive motion (CPM) device provided from October 24, 2020, to November 6, 2020.
You asked the Plan to waive the coinsurance continuous passive motion device. You say that you were told this device would be taken care of, so you should not owe this amount. The Plan denied your request. The Plan says that the coinsurance amount you are being charged is correct.
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 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 CPM device. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide an Explanation of Benefits (EOB) or remittance advice showing the allowed amounts of these claims. We requested this information, but it was not provided to us. Coinsurance is based on a fixed percentage of the allowed amount of a claim. Without evidence of the allowed amounts of these claims, we cannot determine whether the specific coinsurance amounts you are being charged are mathematically correct. Therefore, the Plan has not shown that its decision to ask you to pay a total coinsurance amount of $62.90 is correct or justified according to the Plan contract. Therefore, we decided that the Plan has to waive the coinsurance a continuous passive motion (CPM) device provided from October 24, 2020, to November 6, 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. 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, based on the medical records provided, the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but you do not require an intensive inpatient rehabilitation therapy 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. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a complete oral evaluation (D0150) and an intraoral complete series of radiographic images (D0210).

You asked the Plan to pay for a complete oral evaluation and an intraoral complete series of radiographic images. You say that because the provider could not obtain your records, they did a comprehensive exam and radiographic images even though you did not want them done. You do not think you should have to pay when you did not want them to provide these services. The Plan denied your request. The Plan says the intraoral complete series of radiographic images is not a covered service. The comprehensive oral evaluation is covered once every thirty-six months.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a complete oral evaluation and an intraoral complete series of radiographic images have not been met. Specifically, intraoral complete series of radiographic images is not a covered service of the Plan. The record shows that you had met your benefit maximum for a comprehensive oral evaluation. Therefore, we decided that the Plan does not have to pay for a complete oral evaluation (D0150) and an intraoral complete series of radiographic images (D0210).

Your complaint about the provider completing services you did not ask for is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pontic (D6245) and retainer crowns (D6740 x 2).

You asked the Plan to pre-approve a pontic and retainer crowns. You say that you did not receive the Plan's Annual Notice of Changes (ANOC) and did not know that the Plan is not covering the requested items/services for 2021. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested items/services are not covered.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pontic (D6245) and retainer crowns (D6740 x 2).

Your complaint about not being notified to your satisfaction about changes in the Plan's benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October 29, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were not given a choice 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 you must pay a $300 copayment for ambulance services. You have been asked to pay the allowed amount of $226.18, which is less than the $300 copayment for ambulance services. Ambulance services fall 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 ambulance services provided on October 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression
(PILD) procedure.
You asked the Plan to pre-approve a PILD procedure. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says the enrollee is not enrolled in a clinical study.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
We looked at the file and Medicare rules. Medicare rules say that percutaneous image-guided lumbar
decompression or commercially known as the mild procedure will be covered when provided in an approved
clinical study. The file does not show that the enrollee is enrolled in an approved clinical study. Therefore, we
decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD)
procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for rest home visit provided on October 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for rest home visit. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that these services were not rendered in a participating facility.
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 had network providers available who could have provided 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 rest home visit provided on October 20, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64625).

You asked the Plan to pre-approve radiofrequency ablation. You say that you have trialed nerve block injections and that radiofrequency ablation is the next logical step in the process to relieve your extreme pain. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested procedure is experimental/investigational.

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 radiofrequency ablation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the request is for radiofrequency ablation of the lateral sacral branches. The requested procedure is considered experimental/investigational because of the wide variation in efficacy that has been reported in the 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral periapical radiographic image (D0220) provided on August 3, 2020.
You asked the Plan to pay for a limited oral evaluation and an intraoral periapical radiographic image. You say that due to your allergies you need to see this provider because they have hospital privileges. The Plan denied your request. The Plan says your plan does not provide coverage for services rendered by an out-of-network provider.
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. The Plan covers a limited oral evaluation and an intraoral periapical radiographic image when the services are rendered with an in-network provider. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation and an intraoral periapical radiographic image have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers available to provide these services. 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 a limited oral evaluation (D0140) and an intraoral periapical radiographic image (D0220) provided on August 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (R0075 and Q0092) provided on September 22, 2020.
You asked the Plan to pay for the transportation and set up of a portable x-ray. You say that you would like reconsideration because these services are payable and have been billed correctly. The Plan denied your request. The Plan says these services were not authorized by the Plan.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of a portable x-ray have not been met. Specifically, this claim was billed with place of service code 31 indicating that the member was in a Part A covered SNF stay. These services are not separately billable to Medicare Part B if the member is a Part A covered stay. Additionally, if the member is not in a Part A covered stay, a more appropriate place of service code is required. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (R0075 and Q0092) provided on September 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110).

You asked the Plan to pay for a periodic oral evaluation and prophylaxis. You say that you were not aware that the provider was out-of-network. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation and prophylaxis have not been met. Specifically, services were provided by an Opt out provider. The Plan does not cover dental services when provided by an Opt out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a dual chamber permanent cardiac
pacemaker.
You asked the Plan to pre-approve pacemaker. 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 this
procedure is medically necessary.
The Plan follows Medicare rules. Medicare rules state that pacemakers may be covered for certain, specific
clinical indications.
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 pacemaker. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested pacemaker. Our physician reviewer found
although lower sinus heart rates are reported on the required lower dose sotalol therapy, there is no documented
correlation of sinus bradycardia with the non-specific fatigue and dyspnea symptoms, either by outpatient
cardiac monitoring showing significant, symptomatic bradycardia or by exercise testing demonstrating
chronotropic incompetence with exertion. The enrollee also reports feeling improved in sinus rhythm. In the
absence of specific evidence of bradycardia or chronotropic incompetence correlating with the dyspnea and
fatigue symptoms, she does not currently meet the Medicare coverage indication of non-reversible
symptomatic bradycardia which is required for Medicare coverage of permanent pacemaker implantation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of pacemaker have not been met. Therefore, we decided that the Plan does not
have to pre-approve insertion of a dual chamber permanent cardiac pacemaker.
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 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 enrollee was admitted for surgical treatment of an ankle fracture after a fall. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botulinum Toxin (Botox) injections (J0585).

You asked the Plan to pre-approve the Botox injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that Providers should consult the package insert of each neurotoxin to identify the FDA approved indications for each product. 

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 Botox injections. Our reviewer says that the requested Botox injections are not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the requested Botox treatment is medically necessary for the enrollee's gastroparesis. 

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 Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botulinum Toxin (Botox) injections (J0585).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792).

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for this service was not filed until October 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation with medical services (90792).