Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and appliance (E0673) provided on November 30, 2020.
You asked the Plan to pay for the pneumatic compression device and appliance. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and appliance (E0673) provided on November 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve inpatient hospital services. Our
reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The
enrollee is undergoing an elective right reverse total shoulder replacement. He is medically stable and has been
provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the
Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital
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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on June 18,
2021, to June 22, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you were released from the
hospital too soon causing another inpatient hospital stay a week later. The Plan denied your request. The Plan
says the copayment you are being charged is correct.

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 $295
copayment per day, for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says that
you must pay a $0 copayment per day, for days 6 to 90 for inpatient hospital care.

You have been asked to pay a $295 copayment for inpatient hospital care. The records show you had inpatient
hospital care for four days, resulting in a total cost share of $1,180 ($295 x 4 days = $1,180). The EOC
confirms $295 is the required copayment for this service. 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 care provided on June 18, 2021, to June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like to go to rehabilitation because you
were deemed a severe fall risk by the doctor. The Plan denied your request. The Plan says the stay is not
medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described 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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
non-surgical management of a humerus fracture after a fall and for a urinary tract infection. Medical problems
are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. 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 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 IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from April 12, 2021, through April 19, 2021.

You asked the Plan to waive the copayment for physical therapy. You say that the secretary advised that the plan covered the services, but you received a bill for $350. The Plan denied your request. The Plan says the copayments 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 a $25 copayment for each physical and speech therapy session.

You have been asked to pay a $25 copayment for each physical therapy visit. The total amount you owe is $100 ($25/visit x 4 visits = $100). Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided from April 12, 2021, through April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the two crowns. We decided that the Plan does not have to pay for the core buildup.

You asked the Plan to pay for the crowns - porcelain fused to high noble metal (D2750) x2 and core buildup, including any pins when required (D2950). You say that you obtained the services after the Plan pre-approved the crowns. The Plan denied your request. The Plan says that you have exceeded frequency limits for the crowns. The core buildup is not covered under your benefits.

We decided that the Plan has to pay for the two crowns.

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 one crown per year.

We looked at the file and Medicare rules. Although the Plan contract shows that the Plan only covers one crown per year, the file shows that the Plan issued multiple separate approvals for the requested crowns. The Plan's processing of the prior authorization in this case was ambiguous and confusing enough for you to have reasonably believed that multiple crowns would be covered. Therefore, we decided that the Plan has to pay for the crowns - porcelain fused to high noble metal (D2750) x2 provided March 31, 2021.

We also decided that the Plan does not have to pay for the core buildup.

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 core buildup is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) provided March 31, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) provided on April 19, 2021.
You asked the Plan to pay for the RFA. The Plan denied your request. The Plan says this is not medically 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 pay for the RFA. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational, and therefore, is 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 the RFA have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) provided on April 19, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) and to pay more for the
comprehensive periodontal evaluation (D0180), bitewing x-rays (D0274), panoramic x-ray (D0330), topical
application of fluoride varnish (D1206), and periodontal maintenance (D4910) provided on May 6, 2021 by an
OON provider.
You asked the Plan to pay for the preventive procedure or pay more for the comprehensive periodontal evaluation, bitewing x-rays, panoramic x-ray, topical application of fluoride varnish, and periodontal maintenance. You say that you would never incur these expenses without insurance coverage. The Plan denied your request. The Plan says these services were performed by a non-participating provider and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services. The Plan also says that you did not contact the Plan prior to the services being rendered to verify benefits and eligibility.
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 unspecified preventive procedure (D1999) is not among those covered under this benefit. The contract says that you are responsible for a 50% coinsurance for the periodontal evaluation (D0180), bitewing x-rays (D0274), panoramic x-ray (D0330), topical application of fluoride varnish (D1206), and periodontal maintenance (D4910), plus the difference between the billed and allowed amounts because these services were received OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and to pay more for the comprehensive periodontal evaluation (D0180), bitewing x-rays (D0274), panoramic x-ray (D0330), topical application of fluoride varnish (D1206), and periodontal maintenance (D4910) provided on May 6, 2021 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for initial hospital care (99223) and subsequent
hospital care (99232) provided on July 17, 2020, to July 18, 2020.

You asked the Plan to waive the deductible for initial hospital care and subsequent hospital care. You say that
when you received a statement from the hospital, you were told that the hospital would take care of the bill
with the Plan. You also say that you thought this will include the doctor's bill. You do not feel you should have
to pay the entire bill. The Plan denied your request. The Plan says the deductible you are being charged is
correct.

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 $800 deductible for your covered medical services.

The service at issue is subject to the Plan deductible of $800. The record shows that at the time this claim was
processed, $0 of the $800 deductible had been met. The allowed amount of the claim for initial hospital care is
$238.73, resulting in a deductible obligation of $238.73. The allowed amount of the claim for subsequent
hospital care is $84.78, resulting in a deductible obligation of $84.78. Your total cost share is $323.51.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible for
covered medical services. This cost sharing is a contractual obligation that had not been met at the time initial
hospital care and subsequent hospital care was received on July 17, 2020, to July 18, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for initial hospital care (99223) and subsequent
hospital care (99232) provided on July 17, 2020, to July 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a CPAP device (E0601) provided on July
3, 2021.
You asked the Plan to waive the coinsurance for a CPAP device. You say that you cannot use your CPAP
device due to a recall by the company and that you will no longer pay for a broken, defective, and dangerous
piece of equipment. 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 20%
coinsurance for durable medical equipment.
You have been asked to pay $6.14, or 20% of the Medicare-allowed charge of $30.71, for a CPAP device. A
CPAP device falls 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 CPAP device (E0601) provided on July 3, 2021.
Your complaint about having to continue to pay for a defective device that you are not using 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99335) provided on August 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like reconsideration because the facility should have the authorization for these services. The Plan denied your request. The Plan says prior authorization for non-urgent services was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit (99335) provided on August 28, 2020 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245) provided on April 29, 2021.
You asked the Plan to pay for the pontic. You say that you were told that the bridge would be covered. You say that in the middle of your visit you were told that the service is not covered. You also say that you cannot
afford to pay these bill. The Plan denied your request. The Plan says the pontic is not listed as a covered service.
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 pontic is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pontic (D6245) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive eye exam (92014) provided May 6, 2021.

You asked the Plan to waive the copayment for the vision services. You say that you paid a $40 copayment at the specialist office and you should not have any additional cost-share. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.

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 of the facility fees, plus additional cost sharing for physician services ($0 copayment if conducted by a primary care physician, $40 copayment if conducted by a specialist. 

You have been asked to pay $14.86 for the vision services. The vision services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 comprehensive eye exam (92014) provided May 6, 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 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 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. 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 this enrollee 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: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to pay for the cardiac genetic testing assay provided on December 30, 2020.

You asked the Plan to pay for the cardiac genetic testing assay represented by codes 81408, 81407, 81406, 81405, 81404, 81403, 81401. You say that the enrollee is suspected to have a genetic predisposition to cardiac problems. The Plan denied your request. The Plan says predictive or pre-symptomatic genetic tests in the absence of past or present illness are not covered under Medicare rules.

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, the cardiac genetic testing assay represented by codes 81408, 81407, 81406, 81405, 81404, 81403, 81401, 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 the cardiac genetic testing assay provided on December 30, 2020.