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

We decided that the Plan does not have to waive the cost share for the ultrasound.

You asked the Plan to waive the cost share for the ultrasound. You say that the ultrasound should be considered a part of your preventive exam. You say your cost share should be zero. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $250 deductible that applies towards x-rays and a $45 copayment for each Medicare-covered x-ray after you meet your $250 deductible.

The ultrasound you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies towards x-rays and a $45 copayment for each Medicare-covered x-ray after you meet your $250 deductible. The record shows the Plan billed the ultrasound as a diagnostic mammogram. See provided chart.

This cost sharing is a contractual obligation that had not been met at the time the ultrasound was received. Therefore, we decided that the Plan does not have to waive the cost share for the ultrasound.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered.

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 services are not covered.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded.

We looked at the file and Medicare rules. Billed procedure code G0299 has a status indicator of X and is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the home health services rendered.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit.

You asked the Plan to reduce the copayment for the office visit. You say that you went to the provider to have blood work done. You say you only want to pay the PCP copayment and reimbursed for the urgent care copayment. The Plan denied your request. The Plan says that the claim was billed with a place of service code for an urgent care facility, and 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 claim form showing that the place of service was an urgent care facility. The records support that you were seen by a primary care physician. Therefore, we decided that the Plan has to reduce the copayment for the office visit.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 you are a 68-year-old patient who was admitted to an acute care hospital with heart disease. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical condition does not require intensive physician or nursing supervision in an IRF. You may benefit from additional physical and occupational therapy, but the documentation does not reveal that this therapy must be only on an intensive level 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the echocardiography.

You asked the Plan to reduce the copayment for the echocardiography. You say that you were not notified that the hospital was no longer considered in-network. You say you would have had the Echocardiogram done at another location. The Plan denied your request. The Plan says the Plan has reprocessed the claim and applied the in-network benefit. You have been asked to pay 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 $90 copayment for diagnostic procedures and tests at an in-network outpatient hospital.

You have been asked to pay a $90 copayment for the echocardiography. The echocardiography 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 reduce the copayment for the echocardiography.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the out of network cost share for the oral exam and 2 extractions provided on December 14, 2020.

You asked the Plan to waive the out of network cost share for the dental services. You say that you were referred to this dentist by another dentist. You say that you were not aware that this dentist was non-participating. You also say that you are now being charged a different amount than what you were initially advised. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that you will be responsible for the difference between the Dental Plan's payment to you and the amount charged by the non-participating dentist.

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 and the services are listed as covered, dental services that you receive out of network may cost more. The Evidence of Coverage clearly states that you will be responsible for the difference between the Dental Plan's payment to you and the amount charged by the non-participating dentist. Therefore, we decided that the Plan does not have to waive the out of network cost share for the oral exam and 2 extractions provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the provisional crown (D2799).

You asked the Plan to pay for the provisional crown. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. Therefore, we decided that the Plan does not have to pay for the provisional crown (D2799).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia 250 mg intravenous sol.

You asked the Plan to pre-approve Orencia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria for Orencia has not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Orencia. Our reviewer says that step therapy criteria has not been met. Our physician reviewer found the enrollee is a 65-year-old female with a history of rheumatoid arthritis. The Plan requires a trial of Inflectra or Renflexis before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia 250 mg intravenous sol.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

You asked the Plan to pay for the SNF services. You say that it is felt that Medicare coverage should apply to these dates. The Plan denied your request. The Plan says the care provided on these dates was correctly denied as custodial.

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 necessary. Our physician reviewer found the beneficiary is a 78-year-old female with bradycardia, acute kidney failure and atrial fibrillation. From a nursing perspective, the beneficiary received oral medications.

The beneficiary had stable vital signs. She was treated for pain with effect. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the SNF. By the dates in question, the beneficiary remained non-ambulatory and she required a mechanical lift for transfers. The beneficiary required varying assist with daily living activities.

There were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. This beneficiary did 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 the skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing.

You asked the Plan to pay for genetic tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing/panels except the basic lipid panel.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services.

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Without this document, it cannot be determined that this testing was ordered for Medicare-covered purposes. Based on this information, we decided that Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided by an out-of-network provider.

You asked the Plan to pay for anesthesia. The Plan denied your request. The Plan says services should be received from network providers.

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 anesthesia provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete maxillary denture.

You asked the Plan to pay more for the complete maxillary denture. You say that your maximum benefit has not been reached. The Plan denied your request. The Plan says your calendar year maximum has been reached.

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, a $2,000 combined allowance for supplemental preventive and comprehensive services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the complete maxillary denture.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the radiological diagnostic services.

You asked the Plan to reduce the copayments for the radiological diagnostic services. You say that you were told the copay would be $40. The Plan denied your request. The Plan says you were charged the copayments 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 for Radiological Diagnostic Services.

You have been asked to pay a $100 copayment for the covered radiological diagnostic services. The radiological diagnostic services fall within the Radiological Diagnostic Services benefit category. You were charged a copayment of $100 for the Duplex Scan. You were charged a copayment of $52.22 for the extremity study because the allowable amount was less than your copayment. 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 the radiological diagnostic services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Botox injection rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code J0585 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J0585 is injection, onabotulinumtoxinA, 1 unit. 

We find that CPT code J0585 is not supported in the medical record. Specifically, there is no documentation of an injection of onabotulinumtoxinA. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Botox injection rendered.
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 IRF care is medically necessary to return the enrollee to their functional state. The Plan denied your request. The Plan says rules for IRF care have 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 patient was admitted to an acute care hospital for a heart attack and anemia. Medical problems are stable. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Finally, there is not a reasonable expectation that this patient 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided by an out of network (OON) provider.

You asked the Plan to pay for the OON services. You say that the services were provided in a nursing home setting. The Plan denied your request. The Plan says out-of-network services require authorizations.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available to 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 for the podiatry services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assisted living visit provided by an out of network provider.

You asked the Plan to pay for the assisted living visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent 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 did not pre-approve the service 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 assisted living visit provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the enteral nutrition supplies.

You asked the Plan to pay for the enteral nutrition supplies. You say that these are covered for enrollees in the POS 32. The claim should be paid. The Plan denied your request. The Plan says that the appeal says that the enrollee is in a skilled nursing facility, but the POS code is for nursing facility. Therefore, the POS code is wrong.

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 denial rationale is that the POS code used should be 31. As cited in the Rules section, POS code 31 is appropriate for enrollees in a Part A covered SNF stay, with 32 being used for those in a noncovered stay. Enteral supplies are separately billable during a noncovered stay only. As such, using POS 32 is valid in this case. The Plan provided no evidence to support that POS 31 is the correct code, such as a paid SNF claim showing that Part A coverage was provided for this admission. Therefore, we decided that the Plan has to pay for the enteral nutrition supplies.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular screening test.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for cardiovascular risk assessment panels, except the basic lipid panel.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiovascular screening test.