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

We decided that the Plan does not have to waive the copayment for the visit you had with a dermatology nurse practitioner on May 11, 2021.

You asked the Plan to waive the copayment for the dermatology nurse practitioner visit. You say that because you only saw a nurse, you do not believe the specialist copayment should apply. You stated that the specialist copayment should only apply to services provided by a physician. 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 services obtained by a specialist, or by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office.

You have been asked to pay a $35 copayment for the dermatology nurse practitioner visit. Your Evidence of Coverage explicitly states that the specialist visit copayment will apply not just to physician services, but also to services provided by a nurse practitioner or physician's assistant or other non-physician health care professional in a specialist's office. 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 visit you had with a dermatology nurse practitioner on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home ventilator you rented from January 
28, 2021, to March 28, 2021. 
 
You asked the Plan to waive the coinsurance for the home ventilator. You say that you didn't get billed until 
April even though the charges go back to January. The Plan denied your request. The Plan says you were 
charged this coinsurance 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 durable medical equipment.  
 
You have been asked to pay 20% coinsurance for the home ventilator. The home ventilator falls within the 
durable medical equipment 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 home 
ventilator you rented from January 28, 2021, to March 28, 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 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for selective catheter placement and angiography provided on May 11, 2021.
You asked the Plan to pay for selective catheter placement and angiography. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We asked our coding 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 selective catheter placement and angiography. Our reviewer says that the records do not support the code in dispute. Our codeing reviewer found the operative report does not indicate that CPT code 36215 was separately performed. The elements of the coverage criteria are not satisfied. Coverage for the requested service is not recommended.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of selective catheter placement and angiography have not been met. Therefore, we
decided that the Plan does not have to pay for selective catheter placement and angiography provided on May
11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for denosumab injections (J0897, 96372) provided on May 24, 2021.

You asked the Plan to pay for denosumab injections. You say that this was medically necessary. The Plan denied your request. The Plan says this use of the drug is not supported.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pay for denosumab injections. Our reviewer says that the denosumab injections at issue were not medically supported. Our physician reviewer found there is no documentation of failure of first line bisphosphonate 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 denosumab injections have not been met. Therefore, we decided that the Plan does not have to pay for denosumab injections (J0897, 96372) provided on May 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from January 18, 2021, to
January 30, 2021.

You asked the Plan to pay for home health services. You say that records have been submitted to support these
services. The Plan denied your request. The Plan says the provider of these services is not enrolled in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for home health services provided from
January 18, 2021, to January 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cystoscopy procedure you had at an ambulatory surgery center on June 14, 2021.

You asked the Plan to waive the copayment for the cystoscopy procedure. You say that this procedure was less involved than a colonoscopy, so the copayment should be less. 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 $315 copayment for outpatient surgery in an ambulatory surgery center. 

You have been asked to pay a $315 copayment for the cystoscopy procedure. A cystoscopy is considered a surgical procedure, so the outpatient surgery cost sharing applies. 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 cystoscopy procedure you had at an ambulatory surgery center on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the thromboendarterectomy provided on January 27, 2021.

You asked the Plan to pay for the thromboendarterectomy. You say that the services were provided, and
payment should be rendered. The Plan denied your request. The Plan says based on the documentation
provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.

We asked our coding 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 thromboendarterectomy. Our reviewer
says that the records do not support the codes billed. Our coding reviewer found the criteria for CPT codes
35351 and 35372 are not satisfied. The requested service cannot be recommended.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the thromboendarterectomy have not been met. Therefore, we decided that the
Plan does not have to pay for the thromboendarterectomy provided on January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the specialist visits and the computed 
tomography (CT) scan reading you received while in outpatient observation care from May 8, 2021, to May 13, 
2021. 
 
You asked the Plan to waive the cost sharing for the specialist visits and reading of the CT scan. You say that 
most of the doctors you saw did absolutely nothing for you, so you shouldn't have to pay this cost sharing. The 
Plan denied your request. The Plan says you were charged this cost sharing 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 specialist visits in an outpatient hospital setting.

Records show that you were admitted into an outpatient observation stay from May 8, 2021, to May 13, 2021.  
On May 8, 2021, you had a CT scan.  You had not yet met your deductible at the time of the services, and the 
deductible applies to diagnostic radiology services.  The allowed amount for the reading of this CT scan is 
$48.24.  Since you had not yet met the deductible when you received this service, you are responsible for the 
full allowed amount for the CT scan reading. 
 
On May 10, 2021, you had visits with a neurosurgeon, an orthopedic surgeon, and a pain management 
specialist.  On May 11, 2021, May 12, 2021, and May 13, 2021, you had one visit a day with an orthopedic 
surgeon.  You have been asked to pay a $35 copayment for each of these specialist visits. These copayments 
apply regardless of the reason why you had these visits. 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 sharing for 
the specialist visits and the computed tomography (CT) scan reading you received while in outpatient 
observation care from May 8, 2021, to May 13, 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 you want to return to your independent, prior level of
function and feel you will not recover fully without aggressive therapy in an intensive setting. The Plan denied
your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the care
you need in a less intensive setting.

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 the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs (A9270) provided May 21, 2021.

You asked the Plan to pay for the self-administered drugs. You say that the Ondansetron 4mg tablet should be covered. The Plan denied your request. The Plan says self-administered drugs provided in the outpatient setting are not covered under the Part B medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs (A9270) provided May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone graft for teeth 23 to 27 and implant for teeth 23
to 25.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services
when the services are medically necessary and reasonable.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you are missing
more than one tooth in the arch requested for treatment. The criteria for coverage are not met. The bone graft is
for the implants. Since the implants are not covered, the bone graft is also not covered.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a bone graft for teeth 23 to 27 and implant for teeth 23 to 25.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the SNF admission. You say that you feel that SNF care is needed based on your doctor's opinion. The Plan denied your request. The Plan says you do not require skilled services on a daily basis.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital on 10/3/2021 with acute respiratory failure likely due to aspiration pneumonia and mild heart attack. He has had a feeding tube placed. No skilled nursing needs are identified or documented. Functionally, he is able to transfer with contact guard assistance to a rolling walker and, with a right leg prosthesis, can ambulate up to 200 feet with the walker and contact guard assistance. The enrollee does not meet criteria for a SNF stay as there is no need for daily skilled nursing care and daily skilled therapy is also not required. Less than daily therapy would allow the enrollee's needs to be met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the two breast ultrasounds you had on July 
28, 2020. 
 
You asked the Plan to waive the copayment for the two breast ultrasounds. You say that you were not informed 
of the cost, so you had no opportunity to decline the services. 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 $100 
copayment for each radiological diagnostic service, including ultrasounds.  
 
You have been asked to pay a $100 copayment for the two breast ultrasounds. This is a per-service copayment 
that is laid out in your Evidence of Coverage.  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 two 
breast ultrasounds you had on July 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 20, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the Plan should cover these services because the treatment that you received was medically necessary. The Plan denied your request. The Plan says the Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service.
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 June 20, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on June 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the x-ray exam of the foot
(73630) rendered by the out-of-network (OON) provider on June 8, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the office visit (99203) and the x-ray exam of the foot (73630) rendered by the
out-of-network (OON) provider on June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the device is required. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prednisone, 20 mg tablet. 
 
You asked the Plan to pre-approve prednisone. You say that the enrollee needs this medication. The Plan 
denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone, 20 mg tablet. 

Benefits for prednisone may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.