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

We decided that the Plan does not have to waive the copayment for the SNF care.

You asked the Plan to waive the copayment for SNF care. You say that the SNF care is being denied for services not provided or authorized by designated network providers. You also say that this is the only facility that could take the enrollee. The Plan denied your request. The Plan says the copayment amount that the enrollee is being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copay per day for days 1 to 20, a $178 copay per day for days 21 to 47, and a $0 copay per day for days 48 to 100 for Skilled Nursing Facility (SNF) care up to an in-network maximum out-of-pocket amount of $4,900 for 2020. At the time this claim was processed, $647.44 of the $4,900 in-network maximum out-of-pocket amount had been met. This SNF stay lasted 60 days, which were days 1 to 60 of the benefit period, resulting in a total copayment amount of $4,252.56 because this amount, along with other cost-sharing amounts you have been asked to pay, met the $4,900 in-network maximum out-of-pocket amount for 2020.

The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copay per day for days 1 to 20, a $178 copay per day for days 21 to 47, and a $0 copay per day for days 48 to 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 60 days.

The enrollee has been asked to pay a $0 copay per day for days 1 to 20, a $178 copay per day for days 21 to 47, and a $0 copay per day for days 48 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy and does not have to waive the coinsurance for a Medicare Part B drug.

You asked the Plan to waive the copayment for a colonoscopy and to waive the coinsurance for a Medicare Part B drug. You say that you feel that the claim was processed incorrectly and 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs.

The medical records show that you received a colonoscopy with biopsies. Due to your history of ulcerative colitis, the colonoscopy is considered diagnostic, not preventative. Therefore, you are responsible to pay the $400 copayment.

You received a Medicare Part B drug. The total allowed amount is $167.43 and 20% of that is $33.49.

The total amount you owe is: $433.49.

You have been asked to pay the total amount of $433.49 for a colonoscopy and a Medicare Part B drug. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. A Medicare Part B drug falls within the Medicare Part B 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 copayment for a colonoscopy and does not have to waive the coinsurance for a Medicare Part B drug.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management services (99358).

You asked the Plan to pay for prolonged evaluation and management services. You say that this is a payable code. The Plan denied your request. The Plan says this code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 99358 is prolonged evaluation and management service before and/or after direct patient care; first hour.

We find that CPT code 99358 is not supported in the medical record. Specifically, the record does not show that this service was provided before or after direct patient care. Based on this information, we decided that Medicare rules for coverage of prolonged evaluation and management services have not been met. Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management services (99358).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion Interspinous Spacer.

You asked the Plan to pre-approve the Superion Interspinous Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says this device is experimental.

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 Superion Interspinous Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to prove its safety and efficacy. 

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 Superion Interspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion Interspinous Spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure.

You asked the Plan to pre-approve Ensure. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says Ensure is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.

The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan
does not have to pre-approve Ensure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied towards the diagnostic breast imaging services.

You asked the Plan to waive the deductible applied towards the diagnostic breast imaging services. You say that you had to pay $313 out of pocket towards these services ad you want to know if the Plan can help you with these charges. The Plan denied your request. The Plan says you had not yet met your deductible at the time of this office visit, so you were charged this amount correctly. After processing this claim, you have satisfied your annual deductible and remaining claims will have the applicable cost sharing applied.

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 an $800 annual deductible that applies to outpatient diagnostic tests.

The diagnostic breast imaging services you asked the Plan to waive the deductible applied towards fall within the benefit category outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 annual deductible that applies to outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the diagnostic breast imaging services. Therefore, we decided that the Plan does not have to waive the deductible applied towards the diagnostic breast imaging services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist hand orthosis.

You asked the Plan to pay for the wrist hand orthosis. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 did not pre-approve the wrist hand orthosis. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for a wrist hand orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of BiPAP (E0470).

You asked the Plan to pre-approve the continuation of BiPAP. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says you do not meet adherence criteria.

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 continuation of BiPAP. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records show that you did not use the device more than four hours on 70% of the nights during the trial period. 

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 continuation of BiPAP have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of BiPAP (E0470).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services at a freestanding lab facility.

You asked the Plan to waive the copayment for the lab services. You say that you shouldn't have to pay a copayment because previously you would just walk down to the lab yourself instead of having your doctor send the lab order directly to the lab. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for the lab services ($10.31) is less than your copayment obligation, you are responsible for the full allowed 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 $20 copayment for lab services at a freestanding facility.

You have been asked to pay a $20 copayment for the lab services. Records show that you received these lab services at a freestanding lab facility (not in your doctor's office). That is why the lab services fall within the lab services at a freestanding facility 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 lab services at a freestanding lab facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. You say that you cannot go to any other doctor for these services because you are allergic to many psychological medicines and you have reactions to them. You say that you have been a long time patient of this physician for five years. The Plan denied your request. The Plan says in most situations you must receive prior approval from the Plan before receiving care from out-of-network providers.

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and the periapical X-ray.

You asked the Plan to pay for the oral evaluation and X-ray. You say that the requested services were necessary due to the onset of symptoms. The Plan denied your request. The Plan says the requested services are in excess of your annual benefit allowance.

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 in excess of this benefit. The Plan has submitted evidence that you received two exams and one X-ray earlier in the calendar year. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation and the periapical X-ray.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chewable aspirin and Nitroglycerin tablet.

You asked the Plan to pay for the chewable aspirin and Nitroglycerin tablet. You say that you do not understand how these drugs are considered self-administered, because they were given to you in the emergency room by the registered nurse. The Plan denied your request. The Plan says Medicare generally does not pay for drugs that an enrollee usually self-administers, such as drugs in pill form and those used for self-injection.

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 chewable aspirin and Nitroglycerin tablet.

Benefits for the chewable aspirin and Nitroglycerin tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has spinal stenosis of the lumbar region with neurogenic claudication. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty wheelchair (K0006).

You asked the Plan to pre-approve a heavy-duty wheelchair. You say that this device is medically necessary. The Plan denied your request. The Plan says the heavy-duty wheelchair does not meet medical necessity requirements.

The Plan follows Medicare rules. Medicare rules say that a heavy-duty wheelchair 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 pre-approve a heavy-duty wheelchair. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found you are a 57-year-old male with a past medical history of diabetes, muscle weakness and falling. Based on the documentation presented, the records do not support that a heavy-duty wheelchair is medically reasonable for your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy-duty wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty wheelchair (K0006).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve sacroiliac (SI) joint arthrodesis.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has clearly-documented SI joint pain. She takes oxycodone, Lidoderm, Butrans, Amitriptyline and meloxicam for pain. The requested procedure is the standard of care for the enrollee's condition and is reasonable and medically necessary at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve sacroiliac (SI) joint arthrodesis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT of the Cervical Spine (72125).

You asked the Plan to pre-approve the CT of the Cervical Spine. You say that you would like reconsideration because these tests are necessary to determine why you are experiencing pain. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 CT of the Cervical Spine. Our reviewer says that you are not noted to have any signs or symptoms of anything involving the cervical spine. Our physician reviewer found in this setting, it cannot be said that performance of a CT scan of the cervical spine would be reasonable and necessary given a lack of applicability to your complaints and most likely etiology for your symptoms at the present time. 

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 CT of the Cervical Spine have not been met. Therefore, we decided that the Plan does not have to pre-approve CT of the Cervical Spine (72125).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical records show you do not require skilled nursing or therapy services on a daily basis. Your condition does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria are not 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309).

You asked the Plan to pay for the subsequent nursing facility care. You say that your physician provided medically necessary services in good faith and the rendered services meet professionally recognized standards of healthcare. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309).