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

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 1, 2020.

You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you feel that you should only owe a $50 copayment and cannot afford 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 20% coinsurance for Medicare Part B prescription drugs. 

You received a Medicare Part B drug on December 1, 2020. The total allowed amount is $1,216 and 20% of that is $243.20.

You have been asked to pay the total coinsurance amount of $243.20 for a Medicare Part B drug. A Medicare 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 a Medicare Part B drug provided on December 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplicate flutter valve device (CPT code E0484), for the enrollee.

You asked the Plan to pre-approve the duplicate device. You say that you believe the enrollee was able to receive a new device every six (6) months. The Plan denied your request. The Plan says duplicative durable medical equipment is not medically necessary when it is used as a backup, for use in another home, or for travel.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the duplicate device have not been met. In this instance, the submitted documentation indicates that the enrollee has received the same device on June 15, 2020. This device is still within the 5-year RUL and the documentation submitted does not show that the device is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the device at issue. Based on this information, we decided that Medicare rules for coverage of the duplicate device have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplicate flutter valve device (CPT code E0484), for the enrollee.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to reduce the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided October 7, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not have an option to shop around for less expensive transportation. The Plan denied your request. The Plan says that the copayment was 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 enrollees must pay a $100 copayment for ambulance services per trip, each way. The Plan says you must pay a $150 copayment for the ambulance transport. Based on the Plan contract, however, you cannot be asked to pay more than a $100 copayment for the ambulance transport. Therefore, we decided that the Plan has to reduce the copayment for the ambulance service, basic life support, non-emergency transport (A0428) provided October 7, 2020 from $150 to $100.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional twelve (12) PT visits.

You asked the Plan to pre-approve an additional twelve (12) PT visits. The Plan denied your request. The Plan
says the additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 an additional twelve (12) PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has
been instructed in a home exercise program. The requested services are not part of a maintenance program, are
the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or
deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.

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 additional twelve (12) PT visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve an additional twelve (12) PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99204) to be provided by an
out-of-network provider.

You asked the Plan to pre-approve the services. You say that you would like the enrollee to continue their care
with this provider. The Plan denied your request. The Plan says the out-of-network provider stated the enrollee
can receive urology care within the enrollee's network and does not need to return to their office.

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
the office visit (CPT code 99204) to be provided by an out-of-network provider.
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 inpatient rehabilitation is necessary for you to heal properly and to be able to walk again. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's medical conditions have improved, and care can safely be received in a less intensive setting.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgery to correct a failed knee replacement and dislocated patella. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 pay for continuation of SNF services provided from
November 14, 2020, through November 17, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary after November 13, 2020.
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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her appetite was good. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a modified independent to independent level with functional mobility including gait to 300 feet with a rolling walker. The enrollee required varying assist with activities of daily living. 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. As a practical matter, 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from November 14, 2020, through
November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for laboratory services provided on October 14, 2020.
You asked the Plan to waive the deductible for laboratory services. You say that you were assured that the provider was in-network. 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. Your contract with the Plan says that there is a $750 deductible for out-of-network outpatient diagnostic tests and therapeutic services and supplies. You received laboratory services from an out-of-network provider on October 14, 2020. Therefore, you are responsible to pay your share of the out-of-network cost-sharing charges. The record shows that you had only paid $398.47 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the total allowed amount of $351.53.
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time laboratory services were received on October 14, 2020. Therefore, we decided that the Plan does not have to waive the deductible for laboratory services provided on October 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting.
You asked the Plan to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939). You say that the enrollee needs this procedure for severe back pain relief. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-review literature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939). Our reviewer says that the requested services are not considered medically
reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of bone marrow aspirate. Iliac crest bone graft is the gold standard. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939) have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 24, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on December 4, 2020, through December 5, 2020.

You asked the Plan to waive the copayment for inpatient hospital care. You say that the copay is incorrect. The Plan denied your request. The Plan says the cost share 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 $100 copayment per admission for each inpatient stay for inpatient hospital care. 

You have been asked to pay a $100 inpatient hospital care. This service falls within the inpatient hospital 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 inpatient hospital care provided on December 4, 2020, through December 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses you received from an out-of-network provider on December 28, 2020.
You asked the Plan to pay for the contact lenses. The Plan denied your request. The Plan says out-of-network services are not covered.
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 these services when they are provided by an in-network provider. We looked at the file and the Plan's rules. The contact lenses were purchased from an out-of-network provider. Out-of-network routine dental services are not covered under your plan. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have not been met. Therefore, we decided that the Plan does not have to pay for the contact lenses you received from an out-of-network provider on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 14, 2020 by an out of network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician. The Plan says that there are in-network providers available for these services.

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 psychotherapy services provided on December 14, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that therapy services are not reasonable or necessary because there is no expectation of functional improvement within reasonable time period due to the patient's refusal to participate in progressive mobility training.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck provided on January 8, 2021.

You asked the Plan to waive the copayment for an ultrasound of the head and neck. You say that you should not be responsible for the $25 copayment of the ultrasound. You say that the office visit copayment should include the ultrasound. The Plan denied your request. The Plan says the copayment 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 $25 copayment for outpatient diagnostic tests and therapeutic services and supplies. Your contract with the Plan also clearly says that enrollees must pay a $30 copayment for physician/practitioner services, including doctor's office visits and additional radiology copayments when provided during a physician/specialist office visit.

You have been asked to pay a $25 copayment for an ultrasound of the head and neck. The EOC is clear that $25 is the required copayment for this service. An ultrasound of the head and neck fall within the outpatient diagnostic test 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 of the head and neck (76536) provided on January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220), and the intraoral - periapical each additional radiographic image (D0230) received January 27, 2021.
You asked the Plan to pay for the intraoral images. You say that services were performed in-network and should be fully covered by the Plan. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
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. Therefore, we decided that the Plan does not have to pay for the
intraoral - periapical first radiographic image (D0220), and the intraoral - periapical each additional radiographic image (D0230) received January 27, 2021.