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

We decided that the Plan does not have to waive the copayment for the bone density scan provided November 16, 2020.
You asked the Plan to waive the copayment for the diagnostic service. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied
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 $250 copayment for diagnostic radiological services (such as CT, MRI). You have been asked to pay $116.57 for the diagnostic service. Since the allowed amount was less than the copayment amount, you are responsible for the lesser amount. 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 the bone density scan provided November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for specialist services provided on
March 10, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The
Plan denied your request. The Plan says this copayment was charged based on the services provided and your
Plan contract agreement.
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 $40 copayment for specialist services. 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 $40
copayment charged for specialist services provided on March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
February 18, 2021.
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on February 18, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve treatment with CardioMEMS (33289).
You asked the Plan to pre-approve CardioMEMS. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for coverage have not been met because the requested treatment is experimental/investigational.
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 CardioMEMS. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that management of the enrollee's heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping the enrollee with minimal symptoms and has resulted in acute hospitalizations for decompensated congestive heart failure (CHF). CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Given the severe symptoms of recurrent CHF which appears very sensitive to volume loading conditions, complexity of the medical regimen, and the failure to prevent acute CHF hospitalization in the enrollee, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved Food and Drug Administration (FDA) indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational and would meet medical reasonableness and necessity criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve treatment with CardioMEMS (33289).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telephone evaluation and management services provided on January 25, 2021 by an out-of-network provider.
You asked the Plan to pay for telephone evaluation and management services (99441). You say that the COVID codes are valid. The Plan denied your request. The Plan says you did not request prior authorization as required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for telephone evaluation and management services provided on January 25, 2021 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for external mobile cardiovascular telemetry provided on March 8, 2021.
You asked the Plan to pay for external mobile cardiovascular telemetry. You say that the claim should process in-network. The Plan denied your request. The Plan says the allowed amount was processed correctly out-of-network toward the enrollee's deductible.
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 deductible for out-of-network covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time external mobile cardiovascular telemetry was received on March 8, 2021.
The rendering provider and the referring provider are non-participating. Therefore, we decided that the Plan does not have to pay for external mobile cardiovascular telemetry provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on April 5, 2021.
You asked the Plan to waive the copayment for ultrasound. You say that your provider asked you to come back for a follow-up which was somewhat urgent. The Plan denied your request. The Plan says the copayment amount you are 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). Your contract with the Plan clearly says that you must pay $100 copayment for ultrasound. You have been asked to pay the allowed amount of $93.87, which is less than the $100 copayment for ultrasound. Ultrasound 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 an ultrasound provided on April 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 the SNF services. You say that the enrollee needs more rehabilitation to
regain independence prior to returning home. The Plan denied your request. The Plan says the enrollee does not
meet CMS medical necessity criteria.
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 SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that based on the
documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee
is consistently ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance
program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs, as a
practical matter, can be provided at a lower level of care (ex. home, assisted living, long term care).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan rendered on March 23, 2021.
You asked the Plan to waive the copayment for these services. You say that you were told the services would be at no cost. The Plan denied your request. The Plan says the copayment was 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 $75 copayment for Medicare-covered diagnostic radiology services received in an outpatient hospital.
Review of the file shows that you received a CT scan on March 23, 2021. You have been asked to pay a $75 copayment for these services. These services fall within the Medicare-covered diagnostic radiology services received in an outpatient hospital 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. The Plan cannot be held responsible for possible misinformation given by a
provider regarding your cost sharing. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan rendered on March 23, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment a colonoscopy with polyp removal provided on
March 17, 2021.
You asked the Plan to waive the copayment colonoscopy with polyp removal. You say that a colonoscopy
should not have a copayment even if they remove a polyp. The Plan denied your request. The Plan says the
copayment amount you are 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). Your contract with the Plan clearly says that you must pay $250
copayment for colonoscopy with polyp removal at an ambulatory surgical center.
You have been asked to pay $250 copayment for colonoscopy with polyp removal. Colonoscopy with polyp
removal falls within the Outpatient Surgery, Including Services Provided at Outpatient Hospital Facilities and
Ambulatory Surgical Centers benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment a colonoscopy
with polyp removal provided on March 17, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you on December 29, 2020.
You asked the Plan to pay for the services. You say that you were not aware that this was non-contract provider. The Plan denied your request. The Plan says the Medicare allowed rate has been paid.
The Plan must follow Medicare rules. Medicare rules say that for services of a non-contracting, original Medicare, participating provider; there is no balance billing paid by either the plan or the enrollee. We looked at the file and Medicare rules. You were provided services by a non-contract provider. The Plan has paid the in-network Medicare allowable rate. The Plan is not responsible to make additional payment for the amount you are being billed by the Provider. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided to you on December 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that your foot doctors advised for you to wear orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245), retainer crowns - porcelain/ceramic (D6740), prophylaxis - adult (D1110) provided September 23, 2020, and November 19, 2020.
You asked the Plan to pay for the pontic, retainer crowns and dental cleaning. You say that you feel you did
your due diligence in choosing your provider and should not be responsible for the cost of the services. The
Plan denied your request. The Plan says the provider was excluded from participating in federal programs at
the time services were performed and therefore the services cannot be covered.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who is on the OIG sanction list that
identifies those individuals found guilty of fraudulent billing, misrepresentation of credentials, etc.
We looked at the file and Medicare rules. We verified that the dentist who rendered these services has been on
the OIG sanction list since March 19, 1998. Thus, the provider in this case is excluded from receiving Medicare
payment. Therefore, we decided that the Plan does not have to pay for the pontic - porcelain/ceramic (D6245),
retainer crowns - porcelain/ceramic (D6740), prophylaxis - adult (D1110) provided September 23, 2020, and
November 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for eye surgery provided on May 4, 2021.
You asked the Plan to waive the coinsurance for eye surgery. You say that you are on a fixed income and
would be unable to afford the cost of this coinsurance. The Plan denied your request. The Plan says the
coinsurance amount you are 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). Your contract with the Plan clearly says that you must pay 20%
coinsurance for outpatient eye surgery. The allowed amount of this claim is $3,913.04, resulting in a
coinsurance amount of $782.61.
You have been asked to pay 20% coinsurance for eye surgery. Eye surgery falls within the Outpatient Surgery,
Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the coinsurance for eye surgery provided on May 4, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wireless capsule endoscopy.
You asked the Plan to pre-approve wireless capsule endoscopy. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that wireless capsule endoscopy of the small bowel is
considered medically reasonable and necessary when specific criteria is 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 wireless capsule endoscopy. Our
reviewer says that the services are not medically necessary. Our physician reviewer found available records do
not support that enrollee has undergone recent esophagogastroduodenoscopy (EGD) nor colonoscopy to meet
criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve wireless capsule endoscopy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 20, 2021.
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 by an out-of-network provider on April 20, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
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 a maximum of 40 one-way transportation trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.