Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 13, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient surgical services rendered on March 3, 2020.
You asked the Plan to waive the cost sharing for these services. You say that you were not informed of the charges. The Plan denied your request. The Plan says the cost sharing 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 there is $1,000 yearly deductible for your covered medical services and a $350 copayment for each in-network Medicare-covered outpatient surgery after you pay your $1,000 deductible. The item or service you asked the Plan to waive the cost sharing for falls within the outpatient surgical services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on March 3, 2020. The Plan applied the full $1,000 deductible to these services. At this time, your yearly deductible was met. Given that the deductible did not cover the entire cost of the services, you have also been asked to pay a $350 copayment for these services, per the contract with the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the outpatient surgical services rendered on March 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. The Plan denied your request. The Plan says there are in-network providers where the enrollee can receive the 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care from April 19, 2019 through September 25, 2019 provided by an out-of-network provider.
You asked the Plan to waive the copayment for SNF care. You say that you were falsely kept an extra week because the facility kept faxing the reports to the wrong phone number. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 file show that you received SNF care from April 19, 2019 through September 25, 2019 provided by an out-of-network provider. Your EOC states, enrollees must pay 40% coinsurance per stay for each out-of-network SNF stay. You are asked to pay 40% coinsurance for the out-of-network SNF stay. 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 SNF care from April 19, 2019 through September 25, 2019 provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Electrocardiogram (EKG) provided February 13, 2020.
You asked the Plan to waive the copayment for the EKG. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-share was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $110 copayment for diagnostic testing. You have been asked to pay the Medicare allowable amount of $71.57 for the EKG. The EKG falls within the diagnostic testing benefit category. In this case, the allowable amount is less than the $110 copayment noted in the plan contract. 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 Electrocardiogram (EKG) provided February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on May 16, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on May 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chair lift elevator.
You asked the Plan to pre-approve the requested services. You say that the enrollee needs help getting up the stairs. The Plan denied your request. The Plan says the requested services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a chair lift elevator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 20, 2019.
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 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 physician's services provided on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cardiac rhythmic insertion provided by a
participating outpatient hospital on December 13, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you would like this
copayment waived. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390
copayment for outpatient surgery/in-network/surgery services/outpatient hospital.
You have been asked to pay a $390 copayment for an outpatient surgery. The services that were provided are
considered an outpatient surgery; therefore, the correct copayment has been applied. An outpatient surgery falls
within the outpatient surgery/in-network/surgery services/outpatient hospital benefit category. This means that
you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for cardiac rhythmic insertion provided by a participating outpatient
hospital on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan of the brain.
You asked the Plan to pre-approve a PET scan of the brain. You say that the requested FDG PET is medically necessary. The Plan denied your request. The Plan says the requested FDG PET is not medically necessary.
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 a PET scan of the brain. Our reviewer says that the requested FDG PET is not medically necessary. Our physician reviewer found at the present time the applicable NCD states that a PET/CT scan of the brain is only covered for use in the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) under specific requirements. In this case the records provided for review did not suggest that the member has a differential diagnosis between fronto-temporal dementia (FTD) and Alzheimer's disease (AD). Rather the member has been undergoing evaluation for Parkinsonism that may be potentially associated with FTD. This is not an indication for which the NCD supports the use of a PET/CT of the brain. Furthermore, additional requirements set-forth in the NCD have not otherwise been met. These include but are not limited to that a SPECT scan has not been done within the past year for the same purpose (the member is noted to have undergone a SPECT scan in June 2020 for the same condition). In as much this request would not have met the requirements for coverage-and therefore it cannot be determined to be reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan of the brain.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF provided to the enrollee from January 8, 2020 through February 8, 2020 provided by an in-network provider.You asked the Plan to waive the copayment forSNF care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2020 EOC benefits.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 file show that the enrollee received SNF care from January 8, 2020 through February 8, 2020 provided by an in-network provider. The enrollee's EOC states, "enrollees must pay a $20 copayment per day, days 1 to 20 and a $178 copayment per day, days 21 to 100 for in-network SNF care. A new benefit period will begin on day one when you first enroll in a Medicare Advantage plan, or when you have been discharged from skilled care in a skilled nursing facility for 60 consecutive days." The enrollee is asked to pay a $20 copayment per day, days 1 to 20 and a $178 copayment per day for days 21+for the enrollee's in-network SNF care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for SNF provided to the enrollee from January 8, 2020 through February 8, 2020 provided by an in-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray (74018) provided February 24,
2020.
You asked the Plan to waive the copayment for the x-ray. You say that the copayment should be waived. The
Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for Outpatient Diagnostic Radiology.
You have been asked to pay a $50 copayment for the x-ray. The x-ray falls within the Outpatient Diagnostic
Radiology 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 x-ray (74018) provided
February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a steroid injection provided on February
21, 2020.
You asked the Plan to waive the copayment for a steroid injection. You say that you disagree with the charges
because the injection did not work. 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 $400
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
You have been asked to pay a $400 copayment for a steroid injection. A steroid injection falls within the
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a steroid injection provided on
February 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe emergency room visits provided on January 8, 2020.You asked the Plan to waive the copayments forthe emergency room visits. You say that you were billed for three different emergency room visits. You say this is inappropriate as no emergency room visits were mentioned. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment per visit for Medicare-covered emergency care. The enrollee has been asked to pay a $90 copayment for each of the emergency room visits. The emergency room visits fall within the "Emergency care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments forthe emergency room visits provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with chronic systolic congestive heart failure. Workup was negative for pulmonary embolism. Now, the enrollee is non-toxic, but has poor endurance and is on up to 4-liters of supplemental oxygen. Requires moderate assist for lower body activities of daily living and has poor tolerance for activity. The enrollee needs minimal assist for transfers. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lesser level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a lesser level of care. In this case, the member is mostly moderate/minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF intensity is not warranted.
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 pay for a mammogram (77067) provided September 6, 2019.
You asked the Plan to pay for the mammogram. You say that the screening mammogram should be covered.
The Plan denied your request. The Plan says your benefit was exhausted at the time the procedure was
performed.
The Plan must follow Medicare rules. Medicare rules say that a screening mammogram is covered once a year
for women over age 39.
We looked at the file and Medicare rules. The enrollee already had a screening mammogram within the benefit
period. Based on this information, we decided that Medicare rules for coverage of the mammogram have not
been met. Therefore, we decided that the Plan does not have to pay for a mammogram (77067) provided
September 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 27, 2018.
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 not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 11 for an
independent laboratory; however, the file shows that the specimen was obtained in a treatment center setting
and should have been billed with POS code 57. Therefore, we decided that the Plan does not have to pay for the
drug testing rendered on November 27, 2018.
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. You say that the enrollee is on continuous bilevel positive airway pressure (BiPAP) and is unable to wean at the current moment. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 the enrollee does not have typical problems such as weaning from ventilation or specialized wound care that would require LTACH placement. The enrollee is at an appropriate level of care and can be reasonable expected to go to a higher level of care than LTACH. It is not clear that the enrollee is reasonably thought to require at least 25 days of care at the LTACH level. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 11, 2020.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 11, 2020.