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

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from April 7,
2021, to April 30, 2021.

You asked the Plan to pay for SNF. You say that the enrollee was in a skilled nursing managed care stay for
these dates. The Plan denied your request. The Plan says this was billed as a denial request.

The Plan must follow Medicare rules. Medicare rules say that condition code 21 indicates a request for a
Medicare denial notice.

We looked at the file and Medicare rules. This claim was billed with condition code 21, indicating that it was a
request for a denial. Based on this information, we decided that Medicare rules for coverage of SNF have not
been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care
provided from April 7, 2021, to April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, & 87798) provided September 21, 2020.
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 documentation does not support the billed services.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The documentation does not include an order from the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 87634, 87640, & 87798) provided September 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs you received on
December 28, 2020.

You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you were told that you
met your maximum out-of-pocket amount in June, so you shouldn't be responsible for this coinsurance. The
Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan states that you
did not exhaust your out-of-pocket maximum until after this claim processed because a number of your claims
were voided.

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 drugs, including chemotherapy drugs.

You have been asked to pay 20% coinsurance for the chemotherapy drugs. The Plan confirmed that you did not
meet your out-of-pocket maximum until this claim processed. 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 chemotherapy drugs you received on
December 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the additional procedures to construct new crown under existing partial denture framework (D2971).
You asked the Plan to pre-approve the additional procedures to construct new crown under existing partial denture framework (D2971). The Plan denied your request. The Plan says the 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 pre-approve the additional procedures to construct new crown under existing partial denture framework (D2971).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the outpatient surgery you had on May
19, 2021.
You asked the Plan to reduce the coinsurance for the outpatient surgery. You say that you were in the hospital
for more than 24 hours, so the inpatient copayment should apply instead. 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 outpatient surgery.
You have been asked to pay 20% coinsurance for the outpatient surgery. Your Evidence of Coverage explicitly
states that unless your provider has written an order to admit you as an inpatient to the hospital, you are an
outpatient and pay the cost sharing amount for outpatient hospital services. Even if you stay in the hospital
overnight, you might still be considered an outpatient. That is the case here. Although you may have been in
the hospital 24 hours, you were never admitted as an inpatient. That is why the 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 reduce the coinsurance for the outpatient
surgery you had on May 19, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive 1 copayment for the inpatient services. We decided that the Plan does not have to waive 1 copayment for the inpatient hospital services. 

You asked the Plan to waive 1 copayment for the inpatient services. You say that you always waited in the emergency room until a room was available for you. When a room became available, they took you to it without notifying you it was a private room. They gave you no choice. The Plan says that the claim was processed with the correct copayments applied per the Evidence of Coverage.

We decided that the Plan has to waive 1 copayment for the inpatient hospital services. 

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 $390 copayment per day for days 1 to 5 $0 copayment for days 6-90 for the inpatient services.

The plan says you must pay $4,680.00 for the inpatient services.  However, the file shows that for dates of service February 22, 2021, to February 27, 2021, the Plan had processed an extra $390 copayment for 6 days of inpatient services. The Plan contract specifically says there is a $390 copayment per day for days 1 to 5 $0 copayment for days 6-90. Based on the Plan contract, you cannot be asked to pay for more than 6 days.  The correct copayment amount is $4,290.00 ($1,170.00 (3 days) + $1,560.00 (5 days) + $1,560.00 (5 days). Therefore, we decided that the Plan has to waive 1 copayment for the inpatient hospital services. 

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 pay for comprehensive oral exam (D0150) and sales tax (D9985) provided May 27, 2021.
You asked the Plan to pay for the dental services. You say that you were told that the procedure was required to determine the problem and you did not see any other option at the time, so you opted for the procedure. The Plan denied your request. The Plan says the service exceeds the benefit frequency limitation and is not covered under the Plan 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. Procedure code D0150 is covered once every three plan years. The records show this service was previously provided on November 21, 2019. Sales tax is not listed under the list of covered dental services and is not covered under any circumstances.
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 comprehensive oral exam (D0150) and sales tax (D9985) provided May 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the myocardial perfusion imaging services
you received on June 21, 2021, and July 8, 2021.

You asked the Plan to waive the copayments for the myocardial perfusion imaging services. You say that these
copayments should be waived because you were never told there would be a copayment for these 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 $325
copayment for diagnostic radiology services (other than ultrasounds).

You have been asked to pay a $325 copayment for the myocardial perfusion imaging services. The myocardial
perfusion imaging services falls within the diagnostic radiology 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 copayments for the myocardial perfusion imaging services you received on June 21, 2021, and July 8, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS procedure.

You asked the Plan to pre-approve CardioMEMS. You say that evidence demonstrates the utility of CardioMEMS in both clinical and real-world settings. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this is a packaged code and is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 CardioMEMS. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the CardioMEMS heart failure (HF) system is indicated for the measurement and monitoring of pulmonary artery pressure and heart rate in patients with New York Heart Association Class III heart failure who have been hospitalized for heart failure in the previous year. The hemodynamic data is used by physicians for heart failure management, with the goal of reducing heart failure hospitalizations. The use of the CardioMEMS HF system is reasonable for the enrollee in this case, and has both clinical data and expert opinion to back up its use in selected appropriate clinical situations. The use of this device outside of a clinical trial is not precluded by Medicare. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMEMS have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS procedure.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says four visits can be approved to intensely focus on finalizing the home exercise program,
and to continue educating and reinforcing the important of continued adherence to the program.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 services. Our reviewer says that the
requested visits are not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, there is no documentation that skilled therapy services are required to effectively provide
treatment, care, and/or services in order to improve your level of function, or to establish/perform a
maintenance program to maintain your level of function and/or prevent deterioration beyond the now 29
approved occupational therapy treatment visits. The records indicate that you have demonstrated improvement
in function with the provided therapy but continue to have weakness; the records do not document why the now
29 approved occupational therapy visits are inadequate to treat your condition and to establish a home exercise
program going forward. Based on the records provided, utilization of a home exercise program appears to be
indicated after completion of the 29 approved therapy visits.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance rides provided from April 16, 2021, to April 21, 2021.
You asked the Plan to waive the copayments for the ambulance rides. You say that you should not be responsible for the copayments because this was related to the coronavirus. The Plan denied your request. The Plan says you have been asked to pay 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). Your contract with the Plan clearly says that you must pay a $275 copayment per one-way trip by ground or air ambulance.
You have been asked to pay a total of $487.25 for the ambulance rides. The ambulance rides fall within the "Ambulance services" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Copayment
Member Liability
April 16, 2021
Ambulance ride
$476.64
$275
$275
April 21, 2021
Ambulance ride
$212.25
$275
$212.25
Total
$487.25
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 ambulance rides provided from April 16, 2021, to April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to lab services you received on January 22, 2021.
You asked the Plan to waive the deductible applied to the lab services. You say that You did not provide an explanation with your appeal. You simply provided copies of bills you received. The Plan denied your request. The Plan says you were charged this deductible correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to lab services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on January 7, 2021. Therefore, we decided that the Plan does not have to waive the deductible applied to lab services you received on January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from June 5, 2021, to June 7, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not have to pay this copayment because you received poor care. 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 per day for days 1-5 for inpatient hospital care. 

You have been asked to pay a $300 copayment for the inpatient hospital services. This copayment applies regardless of your satisfaction with the services.

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 inpatient hospital services you received from June 5, 2021, to June 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay more for the lab services provided on January 7, 2021.

You asked the Plan to pay more for the lab services. You say that additional payment should be made because
this should have been processed as in-network. The Plan denied your request. The Plan says reimbursement
was made correctly. The member's cost sharing for lab services is the same in-network as it is out-of-network,
and the cost sharing was applied appropriately.

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 $110 deductible that applies to lab services. After the deductible is met, enrollees pay 15%
coinsurance for lab services, regardless of whether they are in-network or out-of-network.

The enrollee has been asked to pay a $110 deductible, and once met, 15% coinsurance, for the lab services.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan and
the Plan has paid the claim appropriately. 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 pay more for the lab
services provided on January 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee requires a fully electric hospital bed. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on May 3, 2021.

You asked the Plan to pay for physical therapy. You say that you were not aware of the member's primary
insurance. The Plan denied your request. The Plan says the services required authorization. No authorization
was obtained.

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
physical therapy. 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 physical therapy provided on May 3, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction study and electrodes rendered on March 22, 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 the services are not covered.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 95909 (nerve conduction studies, 5-6 studies) and 95861 (needle electromyography, two studies). Code 95909 is a column II code with a modifier indicator of 1 when billed with column I code 95861. Code 95909 was not billed with an appropriate modifier to allow for separate payment. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. Billed procedure code A4556 (electrodes, per pair) has a status indicator of P and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the nerve conduction study and electrodes rendered on March 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you are a paraplegic and have always been covered for these supplies. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.