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 provided from September 30, 2020, to October 23, 2020.
You asked the Plan to waive the copayment for SNF care. You say that you had to stay the extra 3 days because you could not walk. 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 a $0 copayment per day for days 1 through 20, and a $178 copayment per day for days 21 through 100 for Skilled Nursing Facility (SNF) care. This SNF stay lasted 23 days, resulting in a total copayment amount of $534. You have been asked to pay a $0 copayment per day for days 1 through 20, and a $178 copayment per day for days 21 through 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) 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 for the SNF care provided from September 30, 2020, to October 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on August 22, 2020 by an out of network (OON) provider.
You asked the Plan to pay for a colonoscopy. You say that you were misled by the patient when it came to what Plan they had. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a colonoscopy provided on August 22, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to waive the copayment for the cardiac catheterization provided on September 24, 2020.
You asked the Plan to reduce the copayment the cardiac catheterization. You say that you had an angiogram and believe you should only have a $90 copayment. You say the stent was not implanted and you were sent home. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the medical records from the date of service at issue. This means, we cannot confirm if the cardiac catheterization was completed. Therefore, we decided that the Plan has to waive the copayment for the cardiac catheterization provided on September 24, 2020.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 25, 2020, to April 26, 2020.
You asked the Plan to pay for the home health services. You say that this claim was submitted timely and should be paid. The Plan denied your request. The Plan says the date of service span of this claim is more than 30 days which is not allowed.
The Plan must follow Medicare rules. Medicare rules say that for HH PPS billing for dates after 1/1/2020, payment is made per episode of care. Each episode of care is up to 30 days. In this case, the claim at issue is billing for an episode of care that spans 32 days. Any services provided on the final two days of this episode would be billed on a second claim. Therefore, we decided that the Plan does not have to pay for the home health services provided from March 25, 2020, to April 26, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided November 21, 2020, through November 23, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was necessary. The Plan denied your request. The Plan says that the stay was not 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 review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that your 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 November 21, 2020, through November 23, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.
You asked the Plan to pre-approve SNF admission. You say that you would like reconsideration because the SNF admission is medically necessary. The Plan denied your request. The Plan says the member does not have skilled needs and lacks the intensity of services.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not have any parental medication; complex wound care or nutrition given via a feeding tube. She is not planning on any rehab services and is receiving hospice services for end of life. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the diagnostic colonoscopy provided on June 25, 2020, by an in-network provider.
You asked the Plan to waive the cost-share for the diagnostic colonoscopy. You say that the colonoscopy was billed incorrectly due to unspecified abdominal pain. The Plan denied your request. The Plan says this was a diagnostic service.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the medical records show that you originally had a Colorguard screening that showed results of a possible positive colon cancer determination. The colonoscopy on June 25, 2020, was not routine but diagnostic, because of the provider's medical notes and diagnosis to further determine the outcome from your Colorguard screening. Thus, the claim submitted as an outpatient service according to your EOC on pages 91-93, applying the $200 facility copayment and 15% coinsurance. 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 the diagnostic colonoscopy provided on June 25, 2020, by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on January 21, 2020 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewings, and prophylaxis. You say that you believe that these services should be covered. The Plan denied your request. The Plan says these services were rendered by an OON provider and are not covered.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewings, and prophylaxis provided on January 21, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
You asked the Plan to pre-approve Euflexxa injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the patient's medical record should contain documentation that fully supports the medical necessity for intra-articular injections of sodium hyaluronate. 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 Euflexxa injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found the documentation provided does not indicate a failure of conservative non-pharmacologic therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa injections (J7323).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on September 18, 2020.
You asked the Plan to pay for the CxBladder testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing coded as 0012M is non-covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay
for the CxBladder testing provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 22, 2020.
You asked the Plan to pay for the physician's 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 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 provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided from June 22, 2020, through June 30, 2020.
You asked the Plan to pay for the outpatient 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 outpatient services provided from June 22, 2020, through
June 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MammaPrint testing provided on October 14, 2020.
You asked the Plan to pay for the testing services. You say that the testing was instrumental in making critical
decision for the treatment of the enrollee. The Plan denied your request. The Plan says there is no information
to determine the eligibility for the testing.
The Plan must follow Medicare rules. Medicare rules say that MammaPrint testing is only covered under
certain medical indications.
We looked at the file and the rules. We find that the testing is not supported in the medical record. Specifically,
the records do not include results of the enrollee's lymph node testing or cancer stage. Based on this
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the
Plan does not have to pay for the MammaPrint testing provided on October 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eyewear provided on October 23, 2020.
You asked the Plan to pay for eyewear. You say that you refuse to pay this amount. The Plan denied your request. The Plan says the denial of additional payment is correct, because you are responsible for any amount over $100 retail price for this routine eyewear.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers $100 combined in-network and out-of-network benefit toward the purchase and fitting of eyeglasses and contact lenses, one per calendar year. The total charge for this routine eyewear is $238. The Plan paid or discounted $123.60, which is more than the $100 total benefit, so you are responsible for any amount beyond this. We looked at the file and the Plan's rules. The Plan has paid this claim such that you are only responsible for the amount above $100 retail price. Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met. Therefore, we decided that the Plan does not have to pay for routine eyewear provided on October 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an LSO (L0650) provided on August 10, 2020.
You asked the Plan to pay for an LSO. You say that the requested item benefits the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the request is not supported by the medical records.
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 pay for an LSO. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the available documentation in the case file does not support that the requested LSO was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by Medicare. It is not documented that the LSO was ordered to reduce pain by restricting mobility of the trunk; or to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to otherwise support weak spinal muscles and/or a deformed spine. It is also documented that the enrollee received an unsolicited call offering a free brace, and that the enrollee did not have a conversation with the provider regarding the need for a back brace, and that per the enrollee's statement the enrollee did not need one. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an LSO have not been met. Therefore, we decided that the Plan does not have to pay for an LSO (L0650) provided on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot 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 pay for foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist visit you had on November 23, 2020.
You asked the Plan to reduce the copayment for the specialist visit. You say that your copayment should only be $45 because you were sent a card that said specialty visits were only $45. The Plan denied your request. The Plan says you were charged this copayment correctly. The card that says specialist visits are $45 is for year 2021. These services occurred in 2020. On your 2020 ID card, it explicitly says that specialist visits have a $50 copayment.
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 $50 copayment for visits with a specialist. You have been asked to pay a $50 copayment for the specialist visit. This is the copayment obligation listed on both your 2020 ID card as well as in your 2020 Evidence of Coverage. 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 copayment for the specialist visit you had on November 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product (D7921) provided on November 20, 2020. You asked the Plan to pay for the dental service. You say that you have been strongly advised to follow this state-of-the-art practice using this method. You say that it is important to you that you replace the tooth that you lost. You say that you need to keep good nutrition in your recovery from Waldenstrom's Macroglobulimia. The Plan denied your request. The Plan says collection and application of autologous blood concentrate product is not listed as a covered dental service. The Plan also says that the use of autologous biologics to replace or restore damaged tissue is experimental and investigational, because its effectiveness has not been established. 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. Additionally, the services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product (D7921) provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on
October 22, 2020.
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 domiciliary or rest home visit. 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 October 22, 2020.