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

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on September 15, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that the provider called the Plan and were told that the injection was covered. You state that you were not aware of the benefits and ask for help paying the bill. 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 Medicare Part B drugs on September 15, 2021. The total allowed amount is $1,194.91 and 20% of that is $238.98. 

You have been asked to pay the total coinsurance amount of $238.98 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided on September 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an incisional biopsy (D7286) provided by an out-of-network provider on April 29, 2021.

You asked the Plan to pay for an incisional biopsy. You say that you needed this biopsy to see if it was cancerous or not. The Plan denied your request. The Plan says the rendered dental service is not a covered 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 an incisional biopsy (D7286) provided by an out-of-network provider on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that the enrollee had a hearing test about a month or
two ago. The provider advised that the enrollee has severe hearing loss in both ears and requires hearing aids.
The Plan denied your request. The Plan says hearing aids must be prescribed by the enrollee's doctor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan contract says
that hearing aids must be prescribed by your doctor. The Plan contract also says that you receive a hearing aid
benefit of $1,510 per fiscal year (July 1 - June 30) and includes molds, modifications supplies and accessories.
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve
hearing aids.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a computed tomography scan (70450) provided on May 30, 2020.

You asked the Plan to pay for a computed tomography scan. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says that this is not separately payable from 70496.

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 states that code 70496 is not separately payable with 70496, which was billed on a separate claim. However, the Plan did not submit the claim on which 70496 was billed and did not submit other documentation, such as a remittance, showing that 70496 and what provider it was billed by. Without this information, the Plan's denial cannot be verified. Therefore, we decided that the Plan has to pay for a computed tomography scan (70450) provided on May 30, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room services provided from August 24, 2021, to August 25, 2021.
You asked the Plan to waive the copayment for emergency room services. You say that you were directed by your primary care physician to go to the nearest emergency room. You also say you were admitted as an inpatient. The Plan denied your request. The Plan says review of your records indicated you were not admitted to inpatient status, therefore, the cost-sharing was applied correctly for the services rendered.
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 $120 copayment for Emergency Care.
You have been asked to pay a $120 copayment for emergency room services. The services at issue fall within the Emergency 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 emergency room services provided from August 24, 2021, to August 25, 2021
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 enrollee meets IRF criteria and would benefit
from this care. The Plan denied your request. The Plan says the requested services are not medically necessary.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee underwent a right below the knee amputation on 1/6/2021. The enrollee
does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require
fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can
be met at a lower level of care.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy on tooth #4 (D3320) and a crown on tooth #4 (D2750).
You asked the Plan to pre-approve endodontic therapy and a crown. You say that you do not agree with the denial and are requesting reconsideration. The Plan denied your request. The Plan says the requested services are not a covered benefit with your 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 pre-approve endodontic therapy on tooth #4 (D3320) and a crown on tooth #4 (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee brace (L1851) and suspension sleeve (L2397),
provided on October 4, 2021.
You asked the Plan to pay for the knee brace and suspension sleeve. You say that the items are medically
necessary. The Plan denied your request. The Plan says these items were obtained by an unsolicited phone call.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the knee brace and
suspension sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the knee
brace (L1851) and suspension sleeve (L2397), provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tracheotomy supplies provided on July 1, 2021, by an
OON provider.

You asked the Plan to pay for the tracheotomy supplies. You say that the items are medically necessary. The
Plan denied your request. The Plan says there was no prior authorization for these items.

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 the tracheotomy supplies provided on July 1,
2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided July 8, 2021, to
July 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that a stay that is 2 midnights or longer is
appropriate for inpatient, not observation. The Plan denied your request. The Plan says the medical record did
not show that at the time of the inpatient admission the admitting physician reasonably expected that the
enrollee's necessary hospital care (including earlier emergency department (ED) and/or observation care)
would span two midnights.
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 does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that based on the provided documentation, the workup was negative following the
fall and the enrollee was hemodynamically stable with acute kidney injury mild, tolerating conservative
treatments under observation care. There was no expectation that the enrollee would require hospital services
that would likely cross 2 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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided July 8, 2021, to July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) level of care.
You asked the Plan to pre-approve the continued SNF level of care. You say that you have tested positive for the Coronavirus and still need continued rehabilitation services because you are not fully recovered yet. You also say that the SNF has the complete equipment to support the physical therapy and occupational therapy. The Plan denied your request. The Plan says the criteria for a continued SNF stay have not been met.
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 the continued SNF level of care. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 continued SNF level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued skilled nursing facility (SNF) level of care
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Ipilimumab.
You asked the Plan to pre-approve Opdivo and Ipilimumab. You say that you would like reconsideration because these drugs are medically necessary. The Plan denied your request. The Plan says this drug regimen is not being used for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Opdivo and Ipilimumab. Our reviewer says that Opdivo and Ipilimumab are not FDA-approved or indicated by the major drug compendia for the enrollee's diagnosis. Our physician reviewer found the member is currently on Pembrolizumab and these drugs are used as a first line and not for patient's that have progressed on prior PD-L1 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 Opdivo and Ipilimumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Ipilimumab.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on April 2, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON drug testing. You say that this was medically necessary testing needed to guide patient management. The ordering provider was not aware that the lab was OON with the plan. The Plan denied your request. The Plan says neither the ordering provider nor the rendering laboratory was in-network with the Plan. This was routine, non-emergent testing, and no authorization as requested 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 the drug testing provided on April 2, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 13, 2021.

You asked the Plan to pay for lab tests. You say that there is no contractual agreement in place which indicates that these codes are included in the dialysis rate. The Plan denied your request. The Plan says the denial of payment for these tests is correct, because the provider did not bill as required by Medicare coding regulations.

The Plan must follow Medicare rules. Medicare rules say that all lab services furnished to individuals for the treatment of end stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) and are not paid separately. 

We looked at the file and Medicare rules. These lab services are part of the ESRD PPS payment to the dialysis facility and are not separately paid. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health hospital stay provided from July 17, 2020, to July 23, 2020.
You asked the Plan to waive the copayment for the inpatient mental health hospital stay. You say that you did not leave the hospital so there should not be separate charges. 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 $250 copayment per day for days 1-7 for an inpatient mental health hospital stay. The enrollee has been asked to pay a $250 copayment per day, for days 1-6 of the inpatient mental health hospital stay. ($250 x 6 = $1,500). The inpatient mental health hospital stay falls within the "Inpatient mental health care" benefit category. The medical record shows you were inpatient from July 17, 2020, to July 23, 2020.
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 the inpatient mental health hospital stay provided from July 17, 2020, to July 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the
leg joint performed on July 23, 2021.
You asked the Plan to waive the copayment for the MRI. You say that your new disability makes you unable to
afford this copayment. The Plan denied your request. The Plan says the cost-sharing was applied correctly. The
Plan also says that the cost-share amount cannot be waived or reduced due to financial hardship.
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 $150
copayment for advanced radiology services, such as MRIs.
You have been asked to pay a $150 copayment for an MRI. MRIs fall 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 waive the copayment
for Magnetic Resonance Imaging (MRI) of the leg joint performed on July 23, 2021.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at a lower level of care.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for urosepsis and
frequent falls then transferred to a skilled nursing facility on December 11, 2020. The enrollee continues to
receive services in skilled nursing facility. The enrollee's medical conditions are stable. There are no medical
needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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 documents a need for physical and
occupational therapy, it does not document a need for an intensive rehabilitation program. 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. Our physician reviewer found that the enrollee's condition
does not meet Medicare criteria for IRF care.
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 for the enrollee.