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

We decided that the Plan does not have to waive the deductible for the office visit provided on January 6, 2020.
You asked the Plan to waive the deductible for the office visit. You say that you were directed to return for
annual cancer checks. You say that the sister firm covered these cancer checks. The Plan denied your request.
The Plan says the deductible applied correctly.
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 your deductible is $280, which applies to all items and services except those
specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will
pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the
full cost of your covered services. Office visits are not excluded from the deductible.
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $280 deductible applies to office visits. This cost sharing is a contractual
obligation that had not been met at the time the office visit was received on January 6, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for the office visit provided on January 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or
heat exchanger (99190) provided on March 4, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger.
You say that this was a mandatory service. The Plan denied your request. The Plan says payment for this
service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that
CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the
OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as
"inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the
Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger
(99190) provided on March 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for cataract surgery provided on February 27, 2020.
You asked the Plan to waive the cost share for cataract surgery. You say that your eye sight didn't improve. You say that you are wondering if you should be responsible for the bill since you can't see any better. The Plan denied your request. The Plan says the cost share applied correctly.
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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Your contract with the Plan also says that you must pay a $125 copayment after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time cataract surgery was received on February 27, 2020. Therefore, $550.20 has been applied to meet your deductible. Since your $750 deductible was met, you have also been asked to pay the $125 copayment. The records show that the surgery was performed. 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 cataract surgery provided on February 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from July 12, 2019 to August
23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide out-of-network care.
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 has network providers
available who can provide 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 medical services provided from July 12, 2019
to August 23, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, natriuretic peptide, was requested solely for screening purposes. Medicare does
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
the laboratory services rendered on January 22, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on April 9, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the clinic nurse informed you to go to the hospital. You say that you should only be charged $10 for the clinic call. 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 a $90 copayment for each 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. The records show that you were treated in the ER. 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 provided on April 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on February 15,
2019.
You asked the Plan to waive the coinsurance for the Part B drug. You say that you did not believe there would
be any cost for doctor visits. The Plan denied your request. The Plan says a corrected claim was submitted and
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 Medicare Part B prescription drugs.
You have been asked to pay $96 which is 20% of the allowed amount for the Part B drug. The allowed amount
is $480. ($480 x 20% = $96). 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 provided on February 15,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve a prosthetic leg to be provided by an OON provider. You say that the item is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide this item. Therefore, coverage criteria has not been met. 
 
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 a prosthetic leg 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 a Group 3 power wheelchair, electronic upgrades, tilt/recline and elevating leg rests.
You asked the Plan to pre-approve a Group 3 power wheelchair, electronic upgrades, tilt/recline and elevating leg rests. You say that the enrollee needs a Group 3 power wheelchair and accessories to improve the enrollee's seating position. The Plan denied your request. The Plan says criteria for a Group 3 power wheelchair and accessorizes is not met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 3 power wheelchair, electronic upgrades, tilt/recline and elevating leg rests. Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found that the enrollee walks with a cane. On 4/10/20, the enrollee underwent a Seating & Mobility Evaluation. It is documented that the enrollee cannot complete ADLs due to a history of stroke. The enrollee is unable to use a cane or walker to safely accomplish ADLs. The documentation does not support that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, or utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed, or that the power seating system is needed to manage increased tone or spasticity. 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 Group 3 power wheelchair, electronic upgrades, tilt/recline and elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair, electronic upgrades, tilt/recline and elevating leg rests.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the requested item is necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic digital breast to mosynthesis rendered on February 18, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 77062 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 77062. This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay for the diagnostic digital breast to mosynthesis rendered on February 18, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from August 9, 2019 through August 11, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is 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 record show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) 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 August 9, 2019 through August 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on January 29, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 psychotherapy services provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for bitewings - two radiographic images (D0272) provided on
January 23, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan
and you did not elect to purchase an optional supplemental dental coverage.
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. This service is not listed in your EOC as a covered benefit; therefore, it
is not covered. Therefore, we decided that the Plan does not have to pay for bitewings - two radiographic
images (D0272) provided on January 23, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Denosumab.
You asked the Plan to pre-approve Denosumab. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for this drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Denosumab. Our reviewer says that the criteria for coverage of Denosumab have been met. Our physician reviewer found based on the medical records provided, the patient meets the FDA indication for Denosumab and the Plan's guidelines. She has a very low T score of -4.9 with evidence of osteoporotic vertebral compression fractures. There is a notation in the record that she has had one dose of Reclast in the past; it is unclear what her response to the Reclast was, but based on the Plan's guidelines she is not required to re-try the Reclast due to the fracture history. The documentation supports that Denosumab is safe, effective, and medically necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Denosumab have been met. Therefore, we decided that the Plan has to pre-approve Denosumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite, two surfaces, anterior (D2331) and the resin-based composite-four or more surfaces (D2335) provided on January 2, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network dental 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 services provided are not among those covered under this benefit. Additionally, the services were rendered by a non-participating dental provider. Services performed by a non-participating dentist will not be covered under the Plan benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite, two surfaces, anterior (D2331) and the resin-based composite-four or more surfaces (D2335) provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a routine transport for a total of 55.4 miles.
You asked the Plan to pre-approve these services. You say that you need transportation to an appointment. The
Plan denied your request. The Plan says the request exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers routine transportation for up to 48 one-way trips and each one-way trip must not exceed
50 miles.
We looked at your request, the records in the case file, and the rules. The file shows that you are requesting a
one-way trip for a total of 55.4 miles. Based on this information, we decided that the Plan's rules for coverage
of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve a
routine transport for a total of 55.4 miles.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve 1 home health physical therapy visit. 
 
You asked the Plan to pre-approve home health physical therapy. The Plan denied your request. The Plan says that the enrollee no longer requires the skills of a physical therapist. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
The file shows that 6 home health physical therapy visits were requested. The Plan has agreed to pre-approve 5 visits. 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 1 home health physical therapy. Our physician reviewer found that the enrollee has a medical history of COPD, congestive heart failure, and chronic kidney disease. The physical therapy visit on June 22, 2020, documented training 120 feet with a quad cane. The records show that skilled therapy services are required to effectively provide treatment, care, and services in order to improve the enrollee's level of function. It is documented that the enrollee would benefit from continued physical therapy to improve endurance, safety and safe use of a standard cane. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health physical therapy have been met. Therefore, we decided that the Plan has to pre-approve 1 home health physical therapy visit. 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