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

We decided that the Plan does not have to waive the coinsurance for an the Part B drug on August 11, 2020 and September 15, 2020.

You asked the Plan to waive the coinsurance for the Part B drug. You say that you do not agree with these copayment amounts. 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 20% coinsurance for all other drugs covered under Medicare Part B. 

You have been asked to pay $211.20 which is 20% of the allowed amount for the Part B drug. The allowed amount is $1,056. ($1,056 x 20% = $211.20). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drug on August 11, 2020 and September 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery provided on September 16, 2019.

You asked the Plan to waive the copayment for the cataract surgery. You say that you were told the surgery would be 100% covered by insurance. 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 $275 copayment for each covered surgery or observation room service in an outpatient hospital. 

You have been asked to pay a $275 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 cataract surgery provided on September 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray.

You asked the Plan to waive the copayment for the x-ray. You say that the x-ray was necessary and you should not have a copayment. 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 $35 copayment per day, per provider, for in-network Medicare-covered x-ray services.

You have been asked to pay a $35 copayment for the x-ray. The x-ray 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 waive the copayment for the x-ray.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug.

You asked the Plan to pay for the self-administered drug. You say that you need help with these claims. The Plan denied your request. The Plan says the drug that you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules 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 pay for the self-administered drug.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant surgeon services for the knee surgery and biopsy.

You asked the Plan to pay for the assistant surgeon service for the biopsy. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the assistant at surgery claim may not be paid for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 27324. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgeon service for the biopsy have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgeon services for the knee surgery and biopsy.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee could have been evaluated and treated in a lower level of care such as skilled or subacute nursing care facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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. 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 were admitted for respiratory failure and COVID 19 pneumonia. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for extremity artery tests provided on August
10, 2020.

You asked the Plan to waive the copayments for radiological tests. You say that you had the same tests in 2019
with a lower cost-sharing amount. The Plan denied your request. The Plan says the copayment amounts you are
being charged are correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $160
copayment for each extremity artery test. There were two tests provided to you on this date of service. For one
test you have been asked to pay the allowed amount of $147.30, which is less than the $160 copayment for
radiological tests. For the other test, you have been asked to pay the allowed amount of $102.93, which is less
than the $160 copayment for radiological tests. Your total copayment obligation is therefore $250.23.

You have been asked to pay less than $160 copayment for each radiological test. Radiological tests 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 copayments for extremity artery tests provided on August 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 3, 2020, to September 10, 2020.

You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be charged more than 8 days due to the fact that you had to be transferred to a different hospital. 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 $250 copayment for each day for days 1 to 8 for in-network Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days. 

You have been asked to pay a $250 copayment for each day of the inpatient hospital stay. ($250 x 7 inpatient days = $1,750). The inpatient hospital stay falls 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 hospital stay provided from September 3, 2020, to September 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation (D0140), intraoral periapical images (D0220) and resin composite (D2332).

You asked the Plan to pay for limited oral evaluation, intraoral periapical images and resin composite. You say that the services should be covered. The Plan denied your request. The Plan says The Plan says you received care from an out of network provider, for date of service in the amount of $486. The allowed amount was $12. The applicable $100 deductible and $9.60 copayment was applied, and the claim was paid in the amount of $109.86 and the balance of $376.14 can be billed by the 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.

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. Specifically, you received care from an out-of-network provider. This means you can be billed higher than you would be if seen by an in-network provider. The Plan allows $12 (what it would have cost if seen by an in-network provider with your $25 copayment and $100 deductible) towards the services provided and you are responsible for any cost greater than that. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140), intraoral periapical images (D0220) and resin composite (D2332).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the alginate or other fiber gelling dressing (A6196) provided on November 2, 2020.

You asked the Plan to waive the cost share for the alginate or other fiber gelling dressing. You say that you do not agree with this cost share. The Plan denied your request. The Plan says the cost share processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment. 

You have been asked to pay a total cost share of $20.52 for the alginate or other fiber gelling dressing ($102.60 allowed amount x 20% coinsurance). The services provided falls within the durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the alginate or other fiber gelling dressing (A6196) provided on November 2, 2020.

Your complaint about the Plan potentially giving you wrong information 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is not maintained on insulin therapy. The records show that the criteria for coverage of the therapeutic CGM are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) provided on
February 19, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim to be
reconsidered for payment for medical necessity as pneumatic compression devices are a proven treatment for
deep venous thrombosis. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided
that the Plan does not have to pay for a pneumatic compression device (E0676) provided on February 19, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a low dose computed tomography (LDCT) scan for lung cancer
screening (G0297).

You asked the Plan to pay for a LDCT scan. You say that this is a covered service The Plan denied your
request. The Plan says that this was not billed with a diagnosis code that indicates the patient is or was a
smoker.

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 states that the billed diagnoses do not indicate that the enrollee is or
was a smoker but has not provided information as to why the billed diagnosis F17.200, nicotine dependence, is
not sufficient. The submitted medical records indicate that the enrollee is a current smoker with a 30-pack-year
history, indicating that the criteria for coverage have been met. Therefore, we decided that the Plan has to pay
for a low dose computed tomography (LDCT) scan for lung cancer screening (G0297).

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 pay for physician's services that you provided on April 29, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says authorization was required.

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 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 physician's services that you provided on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular interim complete denture.

You asked the Plan to pay for the mandibular interim complete denture. You say that all of your lower teeth were pulled, and you needed this denture. The Plan denied your request. The Plan says this service is 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 pay for the mandibular interim complete denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic with advanced features (L5828, L5984, L5987, L5925, L5920).

You asked the Plan to pre-approve the prosthetic with advanced features. You say that the prosthetic was 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 a determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities.

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 prosthetic with advanced features. Our reviewer says that the requested prosthetic features are not medically necessary. Our physician reviewer found based on the documentation which describes the patient not likely to ambulate much due to his CHF and use of a power chair, the K3 prosthetic with advanced features would not be appropriate for this patient.

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 prosthetic with advanced features have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic with advanced features (L5828, L5984, L5987, L5925, L5920).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance (A0428) and mileage (A0425) provided on October 8, 2020.

You asked the Plan to pay for ambulance and mileage. You say that under most circumstances, CMS does not cover ambulance transportation to a physician's office, so the denial would have been appropriate. However, CMS has issued alternate care sites during the Public Health Emergency - this includes physician's offices to be covered destinations. The Medicare Managed Care Manual, Chapter 11, Section 100.1 says the Managed Care Organization must provide the basic benefits of Medicare Coverage. This means that if CMS is currently allowing physician's offices to be a covered destination, the Managed Care Organization must provide the same benefit. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance and mileage. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this patient. The documentation did not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable and necessary for the patient. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance and mileage have not been met. The expanded list of destinations will apply to medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the PHE for the COVID-19 pandemic. Consistent with section 1861(s)(7) of the Act, there must be a medically necessary ground ambulance transport of a patient in order for an ambulance service to be covered. The enrollee did not meet the medical necessity criteria to have an ambulance transport to a physician's office.

Therefore, we decided that the Plan does not have to pay for non-emergent ambulance (A0428) and mileage (A0425) provided on October 8, 2020.