Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for biofeedback provided by a chiropractor from May 19, 2020,
to June 30, 2020.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says biofeedback services are not covered in a chiropractic setting.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for biofeedback
provided by a chiropractor from May 19, 2020, to June 30, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 23, 2020, to
November 4, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says that the services rendered were not medically
necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the emergency room with weakness and fatigue. The enrollee was
transferred to the Intensive Care Unit. The enrollee's blood pressure required monitoring and use of Cardene
drip. The enrollee continued to have medical management and evaluation by Psychiatry. The enrollee's
condition stabilized, improved and the enrollee was discharged to a skilled nursing facility when medically and
psychiatrically stable. The documentation supports that at the time of inpatient admission, the admitting
physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency
department and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from October 23, 2020, to November 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health care provided to the enrollee on January 27, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care and the provider is not an eligible Medicare provider.
Medicare rules say that plans can require enrollees to get care from network providers. Medicare requires enrollees to get care from Medicare eligible providers. The Plan contract says that enrollees must use network providers and Medicare eligible providers.
The provider in this case is not a network provider with the Plan and is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for out of network mental health care provided to the enrollee on January 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT angiography.

You asked the Plan to waive the copayment for the CT angiography. You say that the doctor requested the scan to check for any leakage. You say that this should be covered under the surgery cost with no patient responsibility. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $125 per day, per in-network provider, for Medicare-covered diagnostic radiology services.

You have been asked to pay a $125 copayment for the CT angiography. The CT angiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate 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 CT angiography.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you left the emergency room after receiving blood work. 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 $90 copayment for emergency care.

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified physical therapist in the HH or hospice setting, direct skilled nursing services of a RN in the HH or hospice setting, and hospice or HH care provided in patient's home/residence provided by an OON provider.

You asked the Plan to pay for the services performed by a qualified physical therapist in the HH or hospice setting, direct skilled nursing services of a RN in the HH or hospice setting, and hospice or HH care provided in patient's home/residence. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior authorization was not requested.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the services performed by a qualified physical therapist in the HH or hospice setting, direct skilled nursing services of a RN in the HH or hospice setting, and hospice or HH care provided in patient's home/residence provided by an
OON provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the services you received at an urgent care facility on June 22, 2020.
You asked the Plan to waive the copayment for the urgent care center services. You say that these services were needed for an open wound on your right hand. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for urgent care facility visits. You have been asked to pay a $10 copayment for the urgent care center 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 copayment for the services you received at an urgent care facility on June 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for to services provided to you by an out-of-network provider on November 17, 2020.
You asked the Plan to pay for the services. You say that you thought that this provider was in-network. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 to services provided to you by an out-of-network provider on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861).
You asked the Plan to pre-approve a group 3 power wheelchair. You say that this item is medically necessary. The Plan denied your request. The Plan says a group 3 power wheelchair is not medically necessary as a group 2 power wheelchair will meet your needs.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees when the Medicare criteria listed in the Medicare rules has been 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 the group 3 power wheelchair. Our reviewer says that this item is not medically necessary and reasonable. Our physician reviewer found there is no documentation from a provided who does not have a financial relationship with the vendor that the enrollee satisfies the requirements for the group 3 power wheelchair, including the need for multiple power options or tilt in space functionality. An independent occupational therapy evaluation of 01/06/2021 recommended a group 2 power wheelchair. 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 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 (K0861).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 20, 2020.
You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis provided on May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays and full mouth debridement provided on November 5, 2020.
You asked the Plan to pay for the complete series of intraoral x-rays and full mouth debridement. You say that you would like these services to be covered. The Plan denied your request. The Plan says your annual $600 allowance has been paid in full.
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 Plan offers a $600 allowance every year for Non-Medicare-covered preventive and comprehensive dental services combined. The contract says that you are responsible for any amount above the dental coverage limit. The record shows that you met the annual maximum benefit while processing this claim for the November 5, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete series of intraoral x-rays and full mouth debridement provided on November 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 4-wheeled walker with a seat attachment.
You asked the Plan to pre-approve the walker. You say that you would like reconsideration because you require a 4-wheeled walker with the seat attachment because you get winded while walking. The Plan denied your request. The Plan says there is no supporting documentation in the medical record showing a change in condition that would require this equipment.
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 walker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you already have a walker. The provided documentation does not indicate that the walker was lost, stolen or is unable to be repaired. 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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a 4-wheeled walker with a seat attachment.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit.

You asked the Plan to waive the copayment for the ER visit. You say that the surgeon advised everything would be covered 90 days post-surgery. The Plan denied your request. The Plan says the copayment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $90 for each Medicare-covered emergency room visit.

You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed after a surgical procedure. 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 ER visit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says transport was not provided.

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. 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December 30, 2019, to January 3, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for days 1-7 for inpatient hospital care. The record shows that you had an inpatient hospital stay from December 30, 2019, to January 3, 2020. Therefore, you are responsible to pay a $200 copayment for days 1-4 (December 30, 2019, to January 2, 2020). $200 (copayment) x 4 (inpatient days) = $800. You have been asked to pay the total copayment amount of $800 for an inpatient hospital stay. An 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 an inpatient hospital stay from December 30, 2019, to January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body, endosteal implant.
You asked the Plan to pay for the endosteal implant. You say that you had no option but to get the implant. The Plan denied your request. The Plan says this is not a service covered by your supplemental benefit.
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 surgical placement of implant body, endosteal implant.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the negative pressure wound therapy pump.

You asked the Plan to waive the coinsurance for the negative pressure wound therapy pump. You say that the cost for this item is exorbitant and you rented an item like this in the past that cost much less. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that the allowed rental amount for this pump is $1589.09, so 10% coinsurance equals $158.91 per month.

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 10% coinsurance for durable medical equipment.

You have been asked to pay 10% coinsurance for the negative pressure wound therapy pump. The negative pressure wound therapy pump 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 coinsurance for the negative pressure wound therapy pump.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that this item was medically necessary. The Plan denied your request. The Plan says there is no evidence of an established relationship between the provider and the enrollee.

The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0648).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on October 9, 2020.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that you disagree with the charges because you were told that you would owe a lesser 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 $510 copayment for nuclear medicine services. You have been asked to pay a $510 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 myocardial perfusion imaging provided on October 9, 2020.