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

We decided that the Plan does not have to reduce the copayment for the CT scan provided on March 10, 2020.
You asked the Plan to reduce the copayment for the CT scan. You say that your payment for the same service last year was only $35. You say you are retired and only receive social security. 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 $125 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a freestanding facility (such as a radiology center or medical clinic). You have been asked to pay a $125 copayment for the CT scan. The CT scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the CT scan provided on March 10, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided by a participating provider on April 8, 2018 to April 30, 2018.
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you were told that these additional costs would be waived. You say that you do not have the money to pay for this. The Plan denied your request. The Plan says the correct copayment 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 $0 copayment per day for days 1-20 and a $100 copayment per day for days 21-23 for skilled nursing facility care. You have been asked to pay a $0 copayment per day for days 1-20 and a $100 copayment per day for days 21-23 for a skilled nursing facility stay. The total amount you are being asked to pay is $300 ($100 x 3 days = $300). The correct copayment has been applied to the services that were provided. A skilled nursing facility stay falls within the skilled nursing facility 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 a skilled nursing facility stay provided by a participating provider on April 8, 2018 to April 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 31, 2020 and April 2, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's 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 physician's services provided on March 31, 2020 and April 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins when required (D2950) provided on January 30, 2020 by an OON provider.
You asked the Plan to pay for the crown and core buildup. You say that the appeal is requested due to what you consider the lack of proper written communication provided by the Plan in the Plan benefits booklet per preventative services. The Plan denied your request. The Plan says the charges exceed the allowable amounts for these procedures. The Plan also says that you may be billed more by an OON provider if the charge is greater than MAC.
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, you are responsible for the difference between the billed amount and allowed amount Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core buildup, including any pins when required (D2950) provided on January 30, 2020 by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with seating and accessories.
You asked the Plan to pre-approve group 3 power wheelchair. You say that the enrollee is a paraplegic and only has use of one hand, and this system would help the enrollee be more mobile. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a second physiatry evaluation should be done to determine the enrollee's needs at this time.
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single or multiple power options is covered when the enrollee meets the clinical criteria as described above and on the previous page, and if the device is medically 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 group 3 power wheelchair. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested power wheelchair. Our physician reviewer found the enrollee's home is wheelchair accessible within as well as entering/exiting with use of a custom ramp. He receives formal in-home support for all of his instrumental and basic care needs. The enrollee's is non-ambulatory with a diagnosis of paraplegia. It is not evident that the enrollee's strength and/or motion deficits could not be safely and adequately addressed with use of an ultralight wheelchair. There is no indication that a Group 2 power mobility device would be insufficient to meet the enrollee's needs. Therefore, the requested Group 3 power wheelchair is not medically 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 group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with seating and accessories.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services or pay for the self-administered drugs you received on January 14, 2020.
You asked the Plan to waive the copayment and pay for the drugs. The Plan denied your request. The Plan says you are responsible for the cost share.
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 copayment for Medicare-covered outpatient surgery. Review of the file shows that you were provided outpatient surgery services and self-administered drugs on January 14, 2020. You have been asked to pay a $250 copayment for the surgery services. The services fall within the outpatient surgery 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. The rules also say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to waive the copayment the outpatient surgical services or pay for the self-administered drugs you received on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 20, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you received a crown and developed several issues from it. You also say that you went back to the dentist in March to have the crown removed. The Plan denied your request. The Plan says benefits for this service are limited to one time per calendar year.
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, emergency diagnostic exams are limited to 1 every year. The record shows that you received a problem focused limited oral evaluation on February 5, 2020 and your emergency diagnostic exam benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on March 20, 2020.
Your complaint about your issues with the providers 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 crown-porcelain fused to high noble metal, tooth 26 (D2750).
You asked the Plan to pre-approve the dental services. You say that a crown must be placed to build back tooth structure for the overall dental health of the enrollee and requests the preauthorization be reprocessed. The Plan denied your request. The Plan says the records do not support the need for replacement of existing crown.
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 the dental services when the services are medically necessary and reasonable. 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 dental services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provider noted that the crown was damaged with craze lines and had poor margins that were causing sensitivity issues. The provided x-rays do not show any appreciable marginal defect that would compromise the existing crown on tooth #26. The described craze lines in the porcelain are not considered grounds for replacement, as it is a cosmetic issue. The integrity of the crown is not compromised from the reported issues. Decay at a margin would be a reason for crown replacement, however this is not seen in this instance. Given there is no demonstrative compromise of the seal of the crown against the tooth, there is no finding of medical necessity for a replacement crown on tooth #26.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pre-approve crown-porcelain fused to high noble metal, tooth 26 (D2750).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for ambulance services provided on March 30, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you were admitted inpatient after an observation stay within the emergency department and should not owe the ambulance copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
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. The Plan did not provide medical records. Without medical records we cannot determine whether the enrollee was admitted inpatient or under observation. Therefore, we decided that the Plan has to waive the copayment for ambulance services provided on March 30, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on July 3, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the documentation did not include a valid physician order or medical records stating exactly what tests are to be performed.
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 codes 80307 and G0482 are not supported in the medical record. There is no evidence that shows the test was individualized to identify specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing services provided on July 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous vertebral augmentation (PVA) surgery provided on February 6, 2020.
You asked the Plan to pay for PVA surgery. You say that you are appealing with medical records to support the service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that PVA surgery is not covered for diagnosis code S32.018A. We looked at the file and Medicare rules. Although Medicare has established limited coverage for this service, this procedure is not covered when performed for diagnosis code S32.018A. Based on this information, we decided that Medicare rules for coverage of PVA surgery have not been met. Therefore, we decided that the Plan does not have to pay for percutaneous vertebral augmentation (PVA) surgery provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on March 12, 2020.
You asked the Plan to pay for endodontic therapy (D3330). You say that your 2020 Enrollment guide references potential dental coverage of this service. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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 pay for the endodontic therapy (D3330) provided on March 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on January 9, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on January 9, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on August 12, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that this was billed to the wrong account. The Plan denied your request. The Plan says the correct copayment 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 $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $40 copayment for physical therapy. The correct copayment has been applied to the services that were provided. Physical therapy falls within the outpatient rehabilitation services/in-network 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 physical therapy provided by a participating provider on August 12, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a Freestyle Libre blood glucose meter system for the enrollee.

You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says that the notes show that insulin is only being used twice a day.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically 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 system. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's diabetes is treated with insulin and oral medications.  According to the documentation, the enrollee takes insulin at baseline and before each meal and he checks his blood glucose four times per day. The monitor is considered therapeutic. The enrollee has been receiving insulin multiple times per day, and the treatment requires frequent adjustment based on the results.

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 system have been met. Therefore, we decided that the Plan has to pre-approve a Freestyle Libre blood glucose meter system 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on March 11, 2020.
You asked the Plan to waive the deductible for an office visit. You say that you disagree with the charges because this was an annual wellness visit. 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 $950 deductible for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit on March 11, 2020 with an out-of-network provider. Therefore, you are responsible to pay your share of the out-of-network charges. The record shows that you had paid $0 toward the $950 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $74.60. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $950 deductible for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on March 11, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on March 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehab.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of an exercise prescription that specifies the target for one or more of the following: heart rate, metabolic equivalent units, rate of perceived exertion, etc.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found while formal cardiac rehabilitation is considered medically necessary in this circumstance, the rehab program must demonstrate minimum standards that include documentation of an exercise prescription, ability for continuous telemetry monitoring and immediate availability of a physician. It is unclear if these parameters have been met. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac rehab.