Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in-network rate for the 5 additional periapical x-rays (D0230) provided on January 8, 2020.You asked the Plan to pay the in-network rate for the 5 additional periapical x-rays. You say that this claim was denied due to confusion with the enrollee's mailing address versus where the enrollee actually resides. You also say that you were given this provider's information by a Plan representative.The Plan denied your request. The Plan says 1 periapical x-ray per calendar year is covered. The Plan also says that the frequency limit has been exceeded.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 periapical x-rays are a covered service, the frequency limit of 1 periapical x-ray per calendar year has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on January 8, 2020.Therefore, we decided that the Plan does not have to pay the in-network rate for the 5 additional periapical x-rays (D0230) provided on January 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transfer chair.
You asked the Plan to pre-approve these services. You say that the enrollee has been approved for a Hoyer lift
but her caregiver is unable to operate it. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that the enrollee has been approved for a Hoyer lift. The requested transfer chair is a lesser
device that serves the same purpose as the Hoyer lift. Therefore, we decided that the Plan does not have to preapprove
a transfer chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Diagnostic digital breast tomosynthesis (77062) provided December 11, 2019.
You asked the Plan to pay for the Diagnostic digital breast tomosynthesis. You say that the service was medically necessary and correctly billed. The Plan denied your request. The Plan says the code billed is not valid for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 77062 is not supported in the medical record. Specifically, per the 2019 National Physician Fee Schedule, this code is marked with an "I" and is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the Diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for a Diagnostic digital breast tomosynthesis (77062) provided December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve face masks (E1399).
You asked the Plan to pre-approve the face masks. You say that you have a heart condition and is currently
taking RX Humira. You have had 2 cases of pneumonia and is concerned about Covid-19. The Plan denied
your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve face masks (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ostomy pouch, drainable; for use on barrier with flange (2 piece system), each (A5063), Skin barrier, wipes or swabs, each (A5120), Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each (A4410) and Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each (A4385) provided to the enrollee from January 20, 2020 through March 23, 2020.You asked the Plan to waive the coinsurance for the supplies. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claims were processed accordingly with the member's 2020 EOC 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). Review of the file show that the enrollee received ostomy and related supplies from January 20, 2020 through March 23, 2020. The enrollee is asked to pay 20% coinsurance for the supplies. According to the member's EOC, enrollees must pay 20% coinsurance for prosthetic devices and medical supplies. 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 coinsurance for ostomy pouch, drainable; for use on barrier with flange (2 piece system), each (A5063), Skin barrier, wipes or swabs, each (A5120), Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each (A4410) and Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each (A4385) provided to the enrollee from January 20, 2020 through March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiography recording provided on January, 28, 2020.You asked the Plan to waive the copayment for the electrocardiographic recording. You say that you should not be charged a copayment for the device because you did not see the doctor on this date of service. 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 $25 copayment for each specialist visit. You have been asked to pay a $25 copayment for the electrocardiographic recording. The electrocardiographic recording falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the electrocardiographic recording is considered a physician 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 electrocardiographic recording provided on January, 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services provided December 3, 2019.You asked the Plan to waive the coinsurance for the inpatient services. You say that the coinsurance should be waived as you thought the procedure was outpatient.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 a 20% coinsurance for Inpatient Hospital Services up to $1,860.You have been asked to pay a 20% coinsurance for the inpatient services. 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 inpatient hospital services provided December 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve routine transportation. You say that you need more rides for healthcare appointments for this year. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 40 one-way trips per year is not covered by the Plan.
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 40 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is still in critical care and needs help with everything. The Plan denied your request. The Plan says the enrollee's needs are being met in the acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH). Initially admitted with shortness of breath, the enrollee suffered a cardiac arrest and severe anoxic brain injury. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee remains on the ventilator. It is unclear that she can be weaned from the ventilator. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the walking boot provided on February 24, 2020.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received the walking boot provided on February 24, 2020. You are asked to pay for the DME at the 18% coinsurance in-network benefit rate. You have been asked to pay 18% coinsurance of the allowed amount for the DME. The allowed amount is $288.24. The total you owe is $51.88 ($288.24 x 18% = $51.88). Your EOC states, enrollees must pay 18% coinsurance for in-network DME, oxygen/ oxygen equipment and related supplies. 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 the walking boot provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on August 19, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment for a SNF stay provided from June 10, 2019 to June 26, 2019.You asked the Plan to waive the deductible and copayment fora SNF stay. You say that you disagree with the charges and would like the plan to take care of the charges with the nursing home.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. Your contract with the Plan says that there is a $975 deductible. Your contract with the Plan also says that after the $975deductible has been met, enrollee's must pay a $250 copayment per day for days 1-58 for out-of-network SNF care. You had a SNF stay from June 10, 2019 to June 26, 2019 with an out-of-network provider. The record shows that you had only paid $418.68toward the $975 deductible prior to receiving the service. Therefore, you are responsible to pay the remaining deductible balance of $556.32. Now that the $975 deductible has been met, you are also responsible to pay $3,452.94, which is less than the total copayment amount. The total amount you owe is: $4,009.26. The item or service you asked the Plan to waive the deductible and coinsurance for falls within the benefit category SNF care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $975 deductible for out-of-network SNF care. The Plan has also followed Medicare rules by clearly disclosing in the contract that after the $975 deductible has been met, enrollee's must pay a $250 copayment per day for days 1-58 for out-of-network SNF care. This cost sharing is a contractual obligation that had not been met at the time a SNF stay was received on June 10, 2019 to June 26, 2019.Therefore, we decided that the Plan does not have to waive the deductible and copayment fora SNF stay provided from June 10, 2019 to June 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness, and an electrical connection You asked the Plan to pre-approve the accessories. You say that this is medically necessary.The Plan denied your request. The Plan says this 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 the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not indicate that you require a proportional input devices (e.g., mini, compact, or short throw joysticks, touch pads, chin control, head control, etc.) other than a standard proportional joystick, a non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need an expandable controller to be able to operate one or more of the following: a separate display (i.e., for alternate control devices); other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) or an attendant control. The documentation indicates that you have sufficient strength and function to control the power features on the wheelchair through their own individual switches.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 accessories have not been met.Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and an electrical connection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on January 13, 2020.You asked the Plan to waive the copayment for the medical eye exam. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a medical eye exam on the date of service at issue in this appeal. The Plan says the correct copayment has applied per your contract with the Plan.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 $30 copayment for medical eye exams. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a medical eye exam on January 13, 2020. You have been asked to pay a $30 copayment for the medical eye exam. The medical eye exam falls 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 copayment for the medical eye exam provided on January 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on December 17, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on December 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 12, 2019 through September 19, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing for reconsideration of the denied charges for a private room. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file shows that you were admitted to an in-network inpatient hospital on September 12, 2019 and discharged on September 19, 2019. The plan reprocessed the claim to remove the private room charge and you are only asked to pay the copayment for inpatient hospital care. You were asked to pay a $360 copayment per day from September 12, 2019 through September 16, 2019, days 1-5 of your inpatient stay. There were no copayment charges from September 17, 2019, day 6 of your inpatient hospital care until your day of discharge September 19, 2019. Per your contract there is a $360 copayment per day required for days 1-5 for in-network inpatient hospital care. 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 inpatient hospital care from September 12, 2019 through September 19, 2019 provided by an in-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your stay beginning May 20, 2020 is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.The file shows that the Plan approved SNF services until May 19, 2020. 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 SNF services beyond May 19, 2020. Our physician reviewer found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a standby assist to contact guard assist with functioning mobility. You require varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.