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

We decided that the Plan does not have to pay for screening digital breast tomosynthesis (77063) screening mammography (77067) complete ultrasound examination of the breast (76641) provided on March 2, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that you request for the Plan to review the attached medical record and reprocess the claim as medically necessary. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 screening digital breast tomosynthesis (77063) screening mammography (77067) complete ultrasound examination of the breast (76641) provided on March 2, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee by an out-of-network provider from July 10, 2020, to August 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 the services provided to the enrollee by an out-of-network provider from July 10, 2020, to August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for tendon sheath incisions provided on March 2, 2021, and March 16, 2021.
You asked the Plan to waive the copayments for tendon sheath incisions. You say that you feel that the Plan should pay more toward the claims. 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 $340 copayment for outpatient surgery, including services provided at ambulatory surgical centers. You received a tendon sheath incision on March 2, 2021, at an ambulatory surgical center. A tendon sheath incision is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $340 copayment.
You received a tendon sheath incision on March 16, 2021, at an ambulatory surgical center. A tendon sheath incision is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $340 copayment. The total amount you owe is: $680. You have been asked to pay the total copayment amount of $680 for tendon sheath incisions. Tendon sheath incisions fall 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 copayments for tendon sheath incisions provided on March 2, 2021, and March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic continuous glucose monitor reader provided on February 24, 2021.

You asked the Plan to pay for the therapeutic continuous glucose monitor reader (K0554). You say that the enrollee met criteria so the Plan should pay this claim. The Plan denied your request. The Plan says the
documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code nor indicate the provider discussed the need for the billed supply code.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day nor requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. The medical records do not show that the CGM was discussed with the enrollee. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor reader (K0554) have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic continuous glucose monitor reader provided on February 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from November 4, 2020, through November 16, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you were informed you were paid up with a $0 balance. You say that you do not owe this, and the bill should be taken care of. The Plan denied your request. The Plan says the copayments 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 a $30 copayment for each Medicare-covered physical therapy and speech-language therapy visit.

You have been asked to pay a $30 copayment for each physical therapy visit. The total amount you owe is $120 ($30/visit x 4 visits = $120). Physical therapy falls within the "Outpatient Rehabilitation Services" benefit category. The records show you paid for 4 of your 8 physical therapy visits leaving a remaining amount of $120. 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 from November 4, 2020, through November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there are no issues in this case for which the LTACH may offer an advantage.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement prosthesis with microprocessor knee and foot (CPT code(s): L5845, L5856, L5968, L5981, L5828), for the enrollee.

You asked the Plan to pre-approve the items. You say that the prosthesis you have proposed is the most back to meet the enrollee's needs. The Plan denied your request. The Plan says documentation submitted does not support medical need for K3 prosthesis with microprocessor knee and ankle.

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 items. Our physician reviewer found the documentation submitted does not support medical need for K3 prosthesis with microprocessor knee and ankle. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

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 items have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement prosthesis with microprocessor knee and foot (CPT code(s): L5845, L5856, L5968, L5981, L5828), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) received April 29, 2021.
You asked the Plan to pay for the application of desensitizing medicament. You say that the Plan should cover the requested service. The Plan denied your request. The Plan says the requested service is not covered under 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 application of desensitizing medicament (D9910) received April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says appropriate care is being received in the inpatient rehabilitation facility.
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 pre-approve the admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee is medically stable with no
documented rehabilitation or nursing needs. The enrollee has made progress in intensive rehabilitation and is at
a level that he can be discharged to community with intermittent therapies. The enrollee can ambulate 150 feet
with supervision.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 8, 2020 through December 9, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the enrollee's stay does not meet Milliman inpatient hospital stay criteria but would meet observation criteria.

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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the medical record did not show 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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from December 8, 2020, through December 9, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on January 7, 2021.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing/panels except the basic lipid panel.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 

This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on January 7, 2021.

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 pre-approve office or other outpatient visit (99213) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office or other outpatient visit. You say that this OON provider is available to provide the medical care you need. The Plan denied your request. The Plan says they have other providers available to provide the care you need.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office or other outpatient visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Support Hose/Fabric Supports.
You asked the Plan to pre-approve the items. You say that the stockings out-of-pocket are too expensive and your primary care physician ordered these stockings for you. You state since the doctor ordered these stockings the insurance should cover them. The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Fabric Supports should be denied, as they are considered a NONREUSABLE SUPPLY; and not a rental type item, and will deny as non-covered. Therefore, we decided that the Plan does not have to pre-approve Support Hose/Fabric Supports.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic mammography (77065) complete ultrasound examination of the breast (76641).

You asked the Plan to waive the copayment for the diagnostic service. You say that you were not aware that you would have a copay of $160. The Plan denied your request. The Plan says this claim was processed with the correct copayments 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 $50 copayment for all other Medicare covered outpatient diagnostic tests and $110 copayment for Medicare covered diagnostic radiology services.

You have been asked to pay $160 ($50 + $110) for the diagnostic service. In this case, copayments of $50 for procedure code 77065 and $110 for procedure code 76641 was applied. The diagnostic service 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 diagnostic mammography (77065) complete ultrasound examination of the breast (76641).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone replacement graft (D7953), and guided tissue regeneration (D4266) provided on April 22, 2021.
You asked the Plan to pay for a bone replacement graft, and guided tissue regeneration. You say that you cannot afford the charges and would like the Plan to help you pay. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 a bone replacement graft (D7953), and guided tissue regeneration (D4266) provided on April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care
provided from February 24, 2021, to March 12, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that you thought the SNF stay would be
completely covered as you believed a new benefit period had started. The Plan denied your request. The Plan
says the copayment has 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $0 copayment per day for days 1-20, and a $172 copayment per day for days 21-100 for skilled
nursing facility care.
The enrollee has been asked to pay a total cost share of $2,752 for the SNF care. In this case, the care you
received was not after a new benefit period had started. All the dates in question were between days 21-100 of
SNF care for the current benefit period (16 days x $172 copayment = $2752). The SNF care falls within the
skilled nursing facility care benefit category. This means that the enrollee has been asked to pay the correct
amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to
pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the skilled nursing facility (SNF) care provided from February 24, 2021, to March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hearing services provided on April 13,
2021.

You asked the Plan to waive the copayment for hearing services. You say that this should be considered a
routine hearing exam. 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 $40
copayment for diagnostic hearing exams and a $0 copayment for routine hearing tests.

The medical records show that you received hearing services due to hearing loss on April 13, 2021. Therefore,
the hearing services are considered diagnostic and you are responsible to pay $10, which is less than the $40
copayment.

You have been asked to pay $10 for hearing services. Hearing services fall within the hearing 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 hearing services provided on April 13, 2021.