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

We decided that the Plan does not have to pay for CPT codes 88237, 88264, 88291, and 4 units of 88280 provided on April 18, 2019.You asked the Plan to pay for CPT codes 88237, 88264, 88291, and 4 units of 88280. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered as billed.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. Medicare rules also say that there is limited coverage for certain CPT codes.In this case, the MUE for CPT code 88280 is 1. You billed 4 units of this code, exceeding the MUE. Furthermore, Medicare says there is limited coverage for CPT codes 88237, 88264, 88291, and 88280 and ICD-10 D89.1 is not a covered diagnosis code for these services. Based on this information, we decided that Medicare rules for coverage of CPT codes 88237, 88264, 88291, and 4 units of 88280 have not been met.
Therefore, we decided that the Plan does not have to pay forCPT codes 88237, 88264, 88291, and 4 units of 88280 provided on April 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of skilled nursing facility (SNF) care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the requested continuation of SNF care does not meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 continuation of skilled nursing facility (SNF) care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/4/20 after being found on the floor. She was diagnosed with a urinary tract infection and admitted to SNF on 1/8/20 with a last covered day of 1/19/20. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the SNF. By the dates in question, the enrollee was at a modified independent to stand by assist level with functional mobility including gait to 160 feet with a hemi-walker. She could negotiate 6 stairs with contact guard assist. The enrollee required varying assist with activities of daily living from independence to minimal assist. She worked with speech therapy on cognition and swallowing.
There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 skilled nursing facility (SNF) care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment for an ultrasound (76641) provided on August 5, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that there should not be a copayment for this service. The Plan denied your request. The Plan says that the contract states you pay a $15 copayment for x-ray services.
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 does not say in clear and accurate terms how much you should expect to pay for an ultrasound. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $15 copayment for an ultrasound. The Plan contract does not clearly say how much enrollees must pay for an ultrasound. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for an ultrasound (76641) provided on August 5, 2019.
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 the medical services provided on September 10, 2018.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide 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 forthe medical services provided on September 10, 2018
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe gym membership fees from May 1, 2017 to May 23, 2019.You asked the Plan to pay for gym membership fees. You say that you were not told that you had this benefit and when you called the plan to ask about it they told you that you did not qualify for gym membership reimbursement.The Plan denied your request. The Plan says the enrollee did not use a participating Silver&Fit facility and therefore cannot be reimbursed.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only With the Silver&Fit program, you can choose a membership at a participating fitness facility or in the Silver&Fit Home Fitness Program.The Plan's rules for coverage of gym benefits have not been met because for coverage you must join a participating Silver&Fit fitness facility or a Silver&Fit Home Fitness Program.Therefore, we decided that the Plan does not have to pay forthe gym membership fees from May 1, 2017 to May 23, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for routine eye exam provided by on April 24, 2019.You asked the Plan to waive the copayment for the eye exam. You say that you had an eye exam and paid the $45 copay but feel you were misdiagnosed and is requesting a second eye exam and do not feel you should have to pay for 2 copays.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 $45 for 1 annual routine eye exam. for Vision care. You have been asked to pay $45 for 1 annual routine eye exam. for the eye exam. the eye exam falls within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forroutine eye exam provided on April 24, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the physical therapy visits provided from
April 24, 2019 to June 11, 2019.
You asked the Plan to reduce the copayments for the physical therapy visits. You say that you were led to
believe you would only have to pay $25 for the physical therapy once, and not each visit. The Plan denied your
request. The Plan says 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 a $25
copayment for each Medicare-covered physical therapy and speech-language therapy visit.
You have been asked to pay a $25 copayment for each of the physical therapy visits. ($25 x 11 visits = $275).
The physical therapy visits fall within the "Outpatient Rehabilitation 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 reduce the copayments for physical therapy visits from April 24, 2019 to June 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five crowns and an interim partial mandibular denture.
You asked the Plan to pre-approve the crowns and denture. You say that these services are urgent because the enrollee is in pain. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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. The contract says that one upper and lower denture covered every 3 years. The record shows that you have already been approved for a complete mandibular denture and your lower denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pre-approve five crowns and an interim partial mandibular denture.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay fora home visit (99349) provided on July 9, 2019 by out of network provider.You asked the Plan to pay fora home visit. You say that you should be paid the allowed amount for this service.The Plan denied your request. The Plan says this service was not authorized.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 fora home visit (99349) provided on July 9, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic pen injector.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 pre-approve Ozempic pen injector.
Benefits for self-administered drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla 28 Day Starter Pack.
You asked the Plan to pre-approve Otezla. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Otezla is not covered under the enrollee's Medicare Part B benefit.
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 pre-approve Otezla 28 Day Starter Pack.
Benefits for Otezla 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from July
17, 2019 to July 21, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says the provider did not bill with an appropriate Q
code and treatment authorization code on the claim.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must
be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that
Medicare rules for completing the claim for home health services have not been met. Specifically, the
submitted claim does not include the required valid treatment authorization code. Therefore, we decided that
the Plan does not have to pay for the home health services provided to the enrollee from July 17, 2019 to July
21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac sodium 1% gel for the enrollee.
You asked the Plan to pre-approve this drug. You say that this medication is helping the enrollee with her bilateral knee pain. The Plan denied your request. The Plan says that this is not covered under Part B.
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 pre-approve Diclofenac sodium 1% gel for the enrollee.
Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on September 13, 2019 by out of network provider.
You asked the Plan to pay for the vision services. You say that you were unaware the provider was not an in-network provider. The Plan denied your request. The Plan says that there is no valid referral for this service.
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 vision services provided on September 13, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided by the doctor on August 13, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you have never been charged this much in the past. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on August 13, 2019. The allowed amount is $1,884.08 and 20% of that is $376.82. You have been asked to pay the total coinsurance amount of $376.82 for a Medicare Part B drug injection. A Medicare Part B drug injection 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 a Medicare Part B drug injection provided by the doctor on August 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were unconscious and an ambulance
was called for you. The responders treated you and gave you an IV because your blood sugar was low. You say
that after treatment you became conscious and your blood sugar levels returned to normal. You refused
transportation to the hospital because your blood sugar was staying at normal levels. The Plan denied your
request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on July 2, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Febuxostat 80 MG tablets.
You asked the Plan to pre-approve Febuxostat. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Febuxostat is not covered under the enrollee's Medicare Part B benefit.
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 pre-approve Febuxostat 80 MG tablets.
Benefits for Febuxostat 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says LTACH admission is not medically necessary.
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 that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for bacteremia attributed to an infected hip. The enrollee has undergone removal of hardware in her hip. The enrollee continues to receive antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by your doctor on June 14, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for services obtained by an out-of-network primary care provider. You had an office visit with an out-of-network provider on June 14, 2019. Therefore, you are responsible to pay the $45 copayment. You have been asked to pay a $45 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 office visit provided by your doctor on June 14, 2019.