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

We decided that the Plan does not have to pay for the subsequent hospital care rendered on January 4, 2021.
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 99232 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 99232 is level 2 subsequent hospital care for evaluation
and management of patient, including expanded problem-focused interval history and medical decision-making
of moderate complexity, typical time 25 minutes.
We find that CPT code 99232 is not supported in the medical record. Specifically, there is no documentation of
25 minutes of level 3 subsequent hospital care spent on the enrollee. 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 subsequent hospital care rendered on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for the evaluation and management of an
established patient (99350) rendered by the OON provider on March 18, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the home visit for the evaluation and management of an established patient (99350)
rendered by the OON provider on March 18, 2021.
Appeal type: SNF
Decision: Unfavorable

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

We decided that the Plan does not have to waive the cost share for the myocardial perfusion imaging,
tomographic (78452), outpatient pharmaceutical medication, and the Regadenoson injection (J2785) provided
on March 26, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the
services provided.
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 per day, per provider for Medicare-covered diagnostic radiology services. Additionally, enrollees
pay a 20% coinsurance for each Medicare Part B covered drug obtained in a provider's office, outpatient
setting, pharmacy, or by mail order.
You have been asked to pay $198.57 which includes a $150 copayment for the Medicare-covered diagnostic
radiology service provided, the Plan allowed amount of $14.24 x 20% coinsurance=$2.85 for the outpatient
pharmaceutical medication, and the Plan allowed amount of $288.58 x 20% =$45.72 for the Regadenoson
injection provided. 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 cost share myocardial perfusion imaging,
tomographic (78452), outpatient pharmaceutical medication, and the Regadenoson injection (J2785) provided
on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on June 2, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta.

You asked the Plan to pre-approve the continuation of care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta. You say that the requested continuation of care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta is medically necessary. The Plan denied your request. The Plan says the requested continuation of care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta is not medically necessary.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.

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 care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta. Our reviewer says that the requested continuation of care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta is not medically necessary. Our physician reviewer found the enrollee is not currently receiving any active treatment and/or medical management of her condition that makes it medically necessary for this enrollee to continue care with the out-of-network tertiary level provider as requested. Letrozole is an oral medication available at most pharmacies. Herceptin and Perjeta are standard maintenance therapies. There is not anything unique about this enrollee's condition that would make it medically necessary for her to continue care with the out-of-network tertiary level provider for chemotherapy. The current treatment is standard. The Plan has shown that they have in-network chemotherapy specialists who have the qualifications and expertise necessary to meet the current medical Standards of Care required for treatment of the enrollee's condition. This enrollee's medical management and/or follow-up care can be safely transitioned to an in-network chemotherapy specialist at this time. Treatment is every 3 weeks and can be given at most oncology infusions centers. 

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 care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of care at an out-of-network tertiary facility for infusion of Herceptin and Perjeta.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided April 26, 2021.
You asked the Plan to pay for the ambulance response. You say that you thought you were saving money by not taking the ambulance ride. The Plan denied your request. The Plan says this service is not covered because there was no transport. The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on April 26, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The record in this case shows that you refused transport to the hospital thus the wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care services provided from March 19, 2021 to April 30, 2021.
You asked the Plan to waive the copayments for the wound care services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgery services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.
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 $270 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received wound care services from March 19, 2021 to April 30, 2021. You have been asked to pay a $270 copayment for each wound care visit. The wound care services fall within the Outpatient surgery 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 wound care services provided from March 19, 2021 to April 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found documentation does not support the need for your continued stay in an SNF due to lack of progress. You are not meeting the expectation of making significant progress in a reasonable period of time. Your care needs can be safely provided at an alternate and lower intensity setting such as in a long-term care (LTC) facility with intermittent therapies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99335) provided on September 1, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that the doctor should not be penalized if authorization was not obtained. The Plan denied your request. The Plan says OON services require 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 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 a domiciliary or rest home visit (99335) provided on September 1, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a commode chair (E0163) provided on February 3, 2021, and a standard low-seat wheelchair (K0002) provided on March 3 to June 3, 2021.
You asked the Plan to waive the coinsurance for a commode chair and a standard low-seat wheelchair. You say that you were not informed and/or aware of the coinsurance for the requested items. The Plan denied your request. The Plan says the correct coinsurance 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 19% coinsurance for durable medical equipment. You have been asked to pay $13.27, or 19% of the Medicare-allowed charge of $69.84, for a commode chair. You have also been asked to pay a total of $38.29, or 19% of the Medicare-allowed charge of $201.53, for a four-month rental for a standard low-seat wheelchair. A commode chair and a standard low-seat wheelchair fall within the "Durable medical equipment (DME) and related 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 coinsurance for a commode chair (E0163) provided on February 3, 2021, and a standard low-seat wheelchair (K0002) provided on March 3 to June 3, 2021.
Your complaint about receiving erroneous or incomplete information about your cost-sharing responsibilities from the provider's office is not a valid appeal for medical coverage. 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ForeseeHome Monitoring System.
You asked the Plan to pre-approve the ForeseeHome Monitoring System. The Plan denied your request. The
Plan says the documentation fails to indicate that there is sufficient literature to establish the effectiveness of
the ForeseeHome Monitoring System and is not considered to be reasonable and 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 the ForeseeHome Monitoring System.
Our reviewer says that the ForeseeHome Monitoring System is not considered medically reasonable and
necessary. Our physician reviewer found that currently there is insufficient evidence that ForeseeHome
Monitoring impacts outcomes of patients with Nonexudative age-related macular degeneration, bilateral,
intermediate dry stage.
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 ForeseeHome Monitoring System have not been met. Therefore, we decided
that the Plan does not have to pre-approve the ForeseeHome Monitoring System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a clinic visit (G0463) provided May 15, 2021.
You asked the Plan to waive the copayment for the clinic visit. You say that the copayment was incorrectly applied. 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 $25 copayment for urgent care visits.
You have been asked to pay a $25 copayment for the clinic visit. The clinic visit falls within the urgent care visits 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 clinic visit (G0463) provided May 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided February 10, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were for screening purposes and were not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, ConfirmMDx, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 30, 2020.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.
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 November 30, 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 requested admission to an IRF does not meet criteria.

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 that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venogram you had on May 7, 2021.
You asked the Plan to waive the copayment for the venogram. You say that this service should be covered in full because it was medically appropriate. 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 $35 copayment for x-rays. You have been asked to pay a $35 copayment for the venogram. The venogram falls within the x-rays 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 venogram you had on May 7, 2021.