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

We decided that the Plan does not have to waive the copayment for an echocardiograph provided on December 1, 2020.

You asked the Plan to waive the copayment for an echocardiograph. You say that you should only owe a $50 copayment. 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 $95 copayment for diagnostic procedures and tests for outpatient hospital services. 

You have been asked to pay a $95 copayment for an echocardiograph. An echocardiograph falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an echocardiograph provided on December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF would be the best setting for the enrollee's care. The Plan denied your request. The Plan says this level of care 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 patient was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient services provided September 29, 2020 to September 30, 2020.

You asked the Plan to waive the copayment for the inpatient services. You say that you do not believe you should be responsible for this bill. You followed your doctor's instructions upon becoming dizzy. You had no idea it would result in a bill of over a thousand dollars. The Plan denied your request. The Plan says the claim was processed and the correct cost share was 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 15% coinsurance for each Medicare covered hospital.

You have been asked to pay $1,117 for the inpatient services. Since you had met your maximum out-of- pocket expense the cost share of $1,289 was reduced to $1,117. The inpatient 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 copayment for the inpatient services provided September 29, 2020 to September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 28, 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. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services rendered on December 17, 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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP, or CNS. We looked at the file and Medicare rules. The file shows that the assistant surgeon is not a physician, PA, NP, or CNS. 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 assistant surgeon services rendered on December 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the compound medication provided on May 6, 2020.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the medicine used for is to be billed under physician services by the physician.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the medication was dispensed by a pharmacy. Since the medication does not represent an expense to the physician, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pay for the compound medication provided on May 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for arthrocentesis and does not have to waive the coinsurance for Medicare Part B drugs provided from September 29, 2020, to October 14, 2020.
You asked the Plan to waive the copayments for arthrocentesis and to waive the coinsurance for Medicare Part B drugs. You say that you feel that the procedures should all be included in one copayment. 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 $225 copayment for outpatient surgery provided at an outpatient hospital facility. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on September 29, 2020. The total allowed amount is $149.23 and 20% of that is $29.85. You received arthrocentesis on October 5, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $225 copayment. You received a Medicare Part B drug on October 5, 2020. The total allowed amount is $140.31 and 20% of that is $28.06. You received arthrocentesis on October 14, 2020, at an outpatient hospital facility. Therefore, you are responsible to pay the $225 copayment. The total amount you owe is: $507.91. You have been asked to pay the total amount of $507.91 for arthrocentesis and Medicare Part B drugs. Arthrocentesis falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drug 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 arthrocentesis and does not have to waive the coinsurance for Medicare Part B drugs provided from September 29, 2020, to October 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for X-rays provided on November 30, 2020.
You asked the Plan to waive the copayment for X-rays. You say that you disagree with the charges. 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 $110
copayment for each Medicare covered radiological diagnostic service.
You have been asked to pay $320.97 for three (3) X-rays, which is less than your $330 copayment ($109.38 + $110 + $101.59 = $320.97). X-rays fall 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 X-rays provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 lab testing services provided on October 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the services provided. You say that there is no other provider in-network that can perform the same level of service. The Plan denied your request. The Plan says the enrollee is required to use network providers to get medical care and services.
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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the lab services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the Guardant360 lab testing services provided on October 1, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-obstetrical transvaginal ultrasound (76830) non-obstetrical transabdominal ultrasound (76856) provided August 20, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you are appealing the amount of the copay that was applied. The Plan denied your request. The Plan says the claim was processed and the correct copayment was 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 $110 copayment for each Medicare covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility.
You have been asked to pay $220 ($110 + $110 = $220) for the diagnostic services. The diagnostic services fall 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 non-obstetrical transvaginal ultrasound (76830) non-obstetrical transabdominal ultrasound (76856) provided August 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc for the enrollee.
You asked the Plan to pre-approve the drug. 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. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the guidelines
preclude the use of viscosupplementation within six months of intra-articular steroids. Therefore, the request is
considered not medically reasonable or necessary.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 6, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 6, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular neurostimulator trial.
You asked the Plan to pre-approve an auricular neurostimulator trial. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
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 an auricular neurostimulator trial. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this would be an experimental/ investigational procedure. There is no evidence of efficacy in chronic low back pain due to scoliosis. The enrollee has other evidence-based therapies available. The request is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an auricular neurostimulator trial have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular neurostimulator trial.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (83883, 86334, 82784, 84165) provided from December 14, 2020.

You asked the Plan to pay for laboratory services. You say that the billed codes are not unlisted procedures. The Plan denied your request. The Plan says that the billed codes require descriptions.

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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Of the billed codes, only 83883 is "not otherwise classified" and requires a description. The claim submitted in the case file includes a description for this service. The Plan has not provided information as to why this description is not sufficient. The Plan has also not provided information substantiating the denial of 86334, 82784, and 84165. These codes are not unlisted or not otherwise classified and do not require a description. Therefore, we decided that the Plan has to pay for laboratory services (83883, 86334, 82784, 84165) provided from December 14, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 11, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 11, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 11, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Capectitabine 500mg tablet for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary for malignant neoplasm of the anal canal. The Plan denied your request. The Plan says that the off-label use of this drug for this condition is not medically accepted.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 services. Our reviewer says that the requested drug is medically reasonable and necessary. Our physician reviewer found although the standard is capecitabine in combination with mitomycin given advanced age it would be better to use some kind of radiosensitizer then none at all. 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 services have been met. Therefore, we decided that the Plan has to pre-approve Capectitabine 500mg tablet for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hip surgery.
You asked the Plan to pre-approve hip surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not met.
The Plan follows Medicare rules. Medicare rules say that Replacement/Revision knee arthroplasty is considered reasonable and necessary when specific criteria is met. 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 hip surgery. Our reviewer says that the services are not medically necessary. Our physician reviewer found criteria for revision total hip surgery not met. There is no evidence of loosening or failure of the prosthesis. There is no evidence of infection of the prosthesis. Revision total hip surgery not justified.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hip surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve hip surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of coverage for SNF services provided from
November 27, 2020, through December 26, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of
SNF services after November 26, 2020 does not meet Medicare's criteria.
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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was alert with confusion. She was treated for pain with effect. She had no signs or symptoms of hyper or hypoglycemia. Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) evaluations in the SNF and had no skilled needs. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of coverage for SNF services provided from November 27, 2020, through December 26, 2020.