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

We decided that the Plan does not have to waive the copayments for the cataract surgeries you had at an
ambulatory surgery center on May 11, 2021, and May 25, 2021.
You asked the Plan to waive the copayments for the two cataract surgeries. You say that you do not understand
the statements you received for these surgeries. You also indicated in your letter that you paid certain fees up
front for these surgeries. The Plan denied your request. The Plan says you were charged these 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 $325
copayment for outpatient surgery in an ambulatory surgery center.
You have been asked to pay a $325 copayment for each of the cataract surgeries. The two cataract surgeries fall
within the outpatient surgery in an ambulatory surgery center 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 copayments for the cataract surgeries you had at an ambulatory surgery center on May 11, 2021,
and May 25, 2021.
Your letter indicates that you may have paid other fees to the provider up front. It is not clear what these fees
are related to, and there is nothing on the claims or Explanations of Benefits that discusses these extra fees.
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to
make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on March 11, 2021.
You asked the Plan to pay for the ambulance service. You say that you needed to be moved to a different facility as an emergency. You say that you requested to be transferred to a different facility so that you could be closer to home. You also say that you feel you should only be responsible for the $75 copayment. The Plan denied your request. The Plan says the ambulance coverage is for transportation to the nearest facility.
The Plan must follow Medicare rules. Medicare rules say that only mileage to the nearest appropriate facility equipped to treat the patient is covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Specifically, the file shows that the facility you were transferred to was not the closest facility that was appropriate to provide treatment. Therefore, we decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a replacement CPAP device.
You asked the Plan to pre-approve a replacement CPAP device. You say that your CPAP device is under recall. The Plan denied your request. The Plan says that that your current CPAP is still under reasonable useful lifetime.
The Plan must follow Medicare rules. The rules say the Plan is responsible for maintaining continuity of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME item. The enrollee's CPAP is under recall for a potential health risk. Therefore, we decided that the Plan has to pre-approve a replacement continuous positive airway pressure (CPAP) device.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) and post and core in addition to crown
(D2954) for tooth #25.
You asked the Plan to pre-approve a crown (D2750) and post and core in addition to crown (D2954). You say
that the front tooth is broken and the veneer is splitting. You say that the tooth needs reconstruction or you may
lose it. The Plan denied your request. The Plan says the services are not covered benefits.
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. Although the post and core is listed as a covered benefit, it would not
be covered when the requested crown is not covered. Therefore, we decided that the Plan does not have to preapprove
a crown (D2750) and post and core in addition to crown (D2954) for tooth #25.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a non-Plan pulmonologist.
You asked the Plan to pre-approve these services. You say that you are dissatisfied with your current
pulmonologist. The Plan denied your request. The Plan says the services are available 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 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 other network
providers available that the enrollee has not seen 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 a referral to a non-Plan pulmonologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example a skilled nursing facility, home with outpatient skilled therapies, or home with home health care skilled therapies.
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 at the current level of medical stability and lack of medical complexity or acuity, there is no need for physician supervision three times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. You are independent with activities of daily living and need stand-by assist for walking. The documentation does not support the need for a therapy program consisting of at least three hours of therapy per day, at least five days a week, with frequent physician oversight, and an interdisciplinary approach to rehabilitation care. You may benefit from an alternate level of care, such as in-home physical therapy for fall reduction, and education to prevent further falls. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) thorax (71250).
You asked the Plan to pre-approve a CT scan. You say that you have multiple sclerosis and had a high red blood cell count. The doctor told you that can mean cancer somewhere in the body. The doctor is requesting different test to see if there is any cancer and where it is located. The Plan denied your request. The Plan says the request for a chest CT is not medically necessary since the already approved PET scan will provide sufficient clinical information.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found a PET scan was approved and is appropriate to help determine the extent of the disease and cause of symptoms. A CT scan would not add any significant information to decide on next clinical steps to take compared to PET scan alone. Therefore, this request for chest CT will be considered not medically 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) thorax (71250).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) services coded 95955 and
the neuromuscular junction testing coded 95937 provided on January 20, 2021.
You asked the Plan to pay for the electroencephalogram (EEG) services and the neuromuscular junction
testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 95955 and 95937 are not supported in the medical record. Specifically, the technical
report did not include documentation of electroencephalogram (EEG) during nonintracranial surgery; therefore,
code 95955 cannot be verified.
The technical report did not include documentation of neuromuscular junction testing (repetitive stimulation,
paired stimuli), each nerve, any 1 method); therefore, code 95937 cannot be verified. Based on this
information, we decided that Medicare rules for coverage of the electroencephalogram (EEG) services and the
neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for
the electroencephalogram (EEG) services coded 95955 and the neuromuscular junction testing coded 95937
provided on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve subsequent hospital care (99232) provided on November 11, 2020.
You asked the Plan to pre-approve subsequent hospital care. You say that the claim was billed correctly, and payment should be rendered. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 two physicians that saw the enrollee of the day in question were not of the same specialty. Therefore, we decided that the Plan has to pre-approve subsequent hospital care (99232) provided on November 11, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve free soft tissue graft procedure (including recipient and
donor surgical sites) first tooth (D4277).

You asked the Plan to pre-approve the dental service. You say that you need this procedure because you are
experiencing pain. You also say that you are at risk of losing teeth. The Plan denied your request. The Plan says
free soft tissue graft procedure (including recipient and donor surgical sites) first tooth is not listed as a covered
service. The Plan also says that you are not enrolled in the optional supplemental dental rider.

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 free
soft tissue graft procedure (including recipient and donor surgical sites) first tooth (D4277).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the daratumumab injection provided on May 28, 2021.

You asked the Plan to waive the coinsurance for the daratumumab injection. You say that the coverage is too minimal due to the amount of the drug cost and being on a fixed income. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug.

You have been asked to pay $1,574.93, which is 20% of the allowed amount for the daratumumab injection. The allowed amount is $7,874.64 (20% x $7,874.64 = $1,574.93). The daratumumab injection 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 the daratumumab injection provided on May 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care provided after October 7, 2021.

You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says SNF care is no longer medically reasonable and necessary.

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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are a 76-year-old man with coronavirus pneumonia and respiratory failure. In this case, there are no identifiable skilled therapy service needs and no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care provided after October 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 12, 2021.

You asked the Plan to pay for the therapeutic activities (97530). You say that the medical records are attached so that the claims can be reprocessed. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.

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, we have confirmed that code 97530 has a bundled relationship with code 92526 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities (97530) provided on February 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the brain you had on May 13, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you need to have an MRI done every six
weeks and you cannot afford the copayment. The Plan denied your request. The Plan says you were charged
this copayment 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 $300
copayment for diagnostic imaging, including MRIs.
You have been asked to pay a $300 copayment for the MRI. The MRI falls within the diagnostic imaging
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging
(MRI) of the brain you had on May 13, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on December 4, 2020.

You asked the Plan to pay for the non-emergent ambulance transportation. You say that the enrollee tested positive for COVID-19, and therefore required highly trained personnel for transfer from the hospital to their assisted living facility. The Plan denied your request. The Plan says the criteria for non-emergent ambulance transportation is not met. The enrollee could have traveled by other transportation. 

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non-emergent ambulance transportation. Our reviewer says that the health plan's denial appears appropriate in this case. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car or other type of vehicle) were contraindicated for this enrollee. Records do not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. These services are not supported as medically reasonable and necessary in this case.

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 non-emergent ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0428, A0425) provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), unspecified periodontal procedure, by report (D4999), unspecified preventive procedure, by report (D1999), and topical application of fluoride varnish (D1206) provided April 7, 2021.
You asked the Plan to pay for the periodontal maintenance, unspecified periodontal procedure, unspecified preventative procedure, and fluoride varnish. You say that you went to your regular dentist and then found out they no longer take Medicare. You have now switched to a new dentist and would like an exception. The Plan denied your request. The Plan says the dental provider has opted out of Medicare, and therefore the services rendered are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the periodontal maintenance, unspecified periodontal procedure, unspecified preventative procedure and fluoride varnish when you see any licensed dental provider who accepts Medicare patients in the United States and has not opted out of Original Medicare. We looked at the file, and Medicare rules. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, we decided that the Plan's rules for coverage of the periodontal maintenance, unspecified periodontal procedure, unspecified preventative procedure and fluoride varnish have not been met. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910), unspecified periodontal procedure, by report (D4999), unspecified preventive procedure, by report (D1999), and topical application of fluoride varnish (D1206) provided April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit you had on November 9, 2020.
You asked the Plan to waive the copayment for the outpatient hospital clinic visit. You say that this should be coded as a wellness visit and there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for outpatient hospital services. The records show that this outpatient hospital clinic visit was for the purpose of evaluating your polyneuropathy, not an annual wellness visit. You have been asked to pay a $10 copayment for the outpatient
hospital clinic visit. The outpatient hospital clinic visit falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital clinic visit you had on November 9, 2020.