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

We decided that the Plan has to pay for Skilled Nursing Facility (SNF) services billed with the Prospective
Patient Driven Model (PDPM) code KAXE1 x 5 days and provided from June 26, 2020, through June 30,
2020.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that the documentation provided does not
support coding of all Section GG payment items which results in a reduction of the PT/OT and nursing
components of the validated PDPM score.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the record indicates that the Plan reviewed clinical documentation
and medical records to substantiate their denial. The documentation submitted does not include any medical
records. Without these records we are unable to determine if the criteria in Section GG of the assessment have
been met. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for Skilled Nursing
Facility (SNF) services billed with the Prospective Patient Driven Model (PDPM) code KAXE1 x 5 days and
provided from June 26, 2020, through June 30, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery for the
enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered
by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device
is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer
found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Vertiflex Superion device placement surgery for the enrollee
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing,
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2751) provided on June 23, 2021.
You asked the Plan to pay for the dental service. You say that you were advised you would have to pay $462 for the services. You also say that you are now being told that you already paid your share and that they were waiting for the plan to pay their part. The Plan denied your request. The Plan says there is a 30% coinsurance for crowns. The Plan says that a payment of $180.30, or 30%, was made for the crown. The Plan says that the member liability is $420.70. The Plan also says that the claim was processed correctly.
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 and the crown is listed as covered, there is a 70% coinsurance when you receive this service in network. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay for the crown (D2751) provided on June 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Mepolizumab injection (J2182) provided on May 21, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service 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 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs.
You have been asked to pay $570.96 (Plan allowed amount of $2,854.80 x 20% coinsurance) for the Medicare Part B drug 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 coinsurance for the Mepolizumab injection (J2182) provided on May 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation rides for doctor appointments. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. The records show that you have used fifty-two (52) one-way transportation trips out of the allowed sixty (60) one-way trips approved. Once 60 trips are used, the benefit will be exhausted. Based on this information, we decided that Plan rules for coverage of additional transports have not been met. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 18, 2020.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore a POS code of 81 - indicating an independent lab setting - is not appropriate for this testing. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for HPV detection by nucleic acid provided on June 15, 2021, and July 20, 2021.
You asked the Plan to waive the copayments for HPV detection by nucleic acid. You say that you should not owe copayments for pap smears and that the test had to be repeated because not enough cells were collected the first time. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $15 copayment for laboratory services. The record shows that you received an HPV detection by nucleic acid test on June 15, 2021. This tests is not included in cervical cancer screenings. Furthermore, you are not being charged a copayment for the preventative codes billed by the provider. Therefore, you are responsible to pay the $15 copayment. The record shows that you received an HPV detection by nucleic acid test on July 20, 2021. This tests is not included in cervical cancer screenings. Furthermore, you are not being charged a copayment for the preventative codes billed by the provider. Therefore, you are responsible to pay the $15 copayment. The total amount you owe is: $30. You have been asked to pay the total copayment amount of $30 for HPV detection by nucleic acid. HPV detection by nucleic acid falls within the outpatient diagnostic tests and therapeutic services and 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 copayments for HPV detection by nucleic acid provided on June 15, 2021, and July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a hammertoe correction provided on April 29, 2021.
You asked the Plan to waive the coinsurance for a hammertoe correction. You say that you should be charged ambulatory surgical center charges and not outpatient hospital charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities. You received a hammertoe correction at an outpatient hospital facility on April 29, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $2,628.99 and 20% of that is $525.80.
You have been asked to pay the total coinsurance amount of $525.80 for a hammertoe correction. A hammertoe correction falls 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 coinsurance for a hammertoe correction provided on April 29, 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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator
You asked the Plan to pre-approve the portable oxygen concentrator. You say that portable oxygen equipment is necessary to make going out easier. The Plan denied your request. The Plan says the enrollee has home oxygen equipment already that is meeting the enrollee's needs.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare also consdiers equipement to be reasonable and necessary if the equipment does not serve the same purpose as other equipment available to an enrollee. The record shows that you have home oxygen equipment. The record does not show that this equipment is not meeting your needs. The portable oxygen equipment serves the same purpose as equipment already provided to the enrollee. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PENS unit (Percutaneous Electrical Nerve Stimulation) (L8679).
You asked the Plan to pre-approve the PENS unit. You say that the enrollee is a good candidate for a PENS unit. The Plan denied your request. The Plan says the device is not covered.
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 PENS unit. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found his device is not covered by the National Coverage Determination and is considered experimental/ investigational.
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 PENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve a PENS unit (Percutaneous Electrical Nerve Stimulation) (L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture (36415), laboratory service (80048), pneumococcal polysaccharide vaccine (90732), and the immunization administration (90471) rendered by the out-of-network (OON) provider on July 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 routine venipuncture (36415), laboratory service (80048), pneumococcal polysaccharide vaccine (90732), and the immunization administration (90471) rendered by the out-of-network (OON) provider on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out-of-network physician services provided to the enrollee
on April 28, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out-of-network physician services provided to the
enrollee on April 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 12, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 11. However, the records do not show that the specimen was collected in an office setting. This
means that the claim was billed with the incorrect POS code. 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 the lab services provided on August 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram with breast tomosynthesis you had at an outpatient hospital facility on May 13, 2021.
You asked the Plan to waive the copayment for the diagnostic mammogram and breast tomosynthesis. You say that you would not have had this service if it wasn't going to be covered. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amounts for these two tests ($83.53 and $23.26) were less than your copayment obligations, you are responsible for the full allowed amount for each test.
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 x-ray in an outpatient hospital facility.
You have been asked to pay a $100 copayment EACH for the diagnostic mammogram and breast tomosynthesis. the diagnostic mammogram and breast tomosynthesis fall within the x-ray in an outpatient hospital facility 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 diagnostic mammogram with breast tomosynthesis you had at an outpatient hospital facility on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and testing services provided on April 14, 2021 to May 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you were told that the provider was in your network. 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 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. The Plan cannot be held responsible for possible misinformation given by a provider regarding network status. Therefore, we decided that the Plan does not have to pay for the office visit and testing services provided on April 14, 2021 to May 26, 2021 by an out-of-network (OON) provider.