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

We decided that the Plan does not have to pay for the services provided by an out=of-network provider on March 11, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out=of-network provider on March 11, 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 the enrollee does not require physical medicine & rehabilitation (PM&R) physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no documented rehab nursing needs, no IV medications and skin care are not chronic. CMS guidelines require that patients make significant progress in a reasonable and predicted period. This enrollee will not be able to meet this expectation based on a physical therapists (PT) note stating the enrollee's activity tolerance is limited and will not tolerate IRF level of therapies. The enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy in an IRF. Documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The enrollee cannot tolerate IRF level of intensity in therapies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a non-participating provider on December 17, 2020, to December 24, 2020.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this copayment. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $390 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care.

You have been asked to pay less than a $390 copayment per day for days 1-5. There is a $0 copayment for
additional days for an inpatient hospital stay. You have been asked to pay $1,692.03, which is less than your
copayment amount of $1,950 ($390 x 5 days = $1,950) due to meeting your out-of-pocket maximum. An
inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a non-participating provider on December
17, 2020, to December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May
11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
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 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 services provided by an out-of-network provider on May 11,
2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic resonance imaging, any joint of
lower extremity (73721) provided April 30, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you needed this MRI
because you fell and hurt your knee. You cannot afford this. You are on a fixed income and do not work. The
Plan denied your request. The Plan says this claim was processed with the correct copayment 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 $300
copayment per visit for all other outpatient diagnostic and therapeutic services and supplies.

You have been asked to pay $281.33 for the diagnostic service. Since the allowed amount was less than the
copayment amount, you are responsible for the lesser amount. The diagnostic service falls within the
Outpatient diagnostic tests and therapeutic services and supplies, such as MRA's, MRI's, CT scans, PET scans
and hyperbaric oxygen therapy. 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
Magnetic resonance imaging, any joint of lower extremity (73721) provided April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for computed tomography, maxillofacial area
(70486) provided April 15, 2021.

You asked the Plan to waive the copayment for the diagnostic services. You say that you are requesting
reconsideration of the financial responsibility of $111.26 for the CT scan you received. The Plan denied your
request. The Plan says this claim was processed with the correct copayment 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 $150
copayment for advanced imaging services in an outpatient hospital.

You have been asked to pay $111.26 for the diagnostic service. Since the allowed amount was less than the
copayment amount, you are responsible for the lesser amount. The diagnostic service 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 copayment for computed tomography, maxillofacial area (70486) provided April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services at the LTACH that the patient requires that are not already available and covered at the current facility.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 4, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 laboratory testing at issue in this appeal 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
laboratory services provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a podiatry office visit provided on March 3, 2021.
You asked the Plan to waive the copayment for podiatry visit. You say that this provider performed extra visits that probably did not need to occur and performed a botched surgery that should not have been performed. The Plan denied your request. The Plan says the copayment amount 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 $35 copayment for in-network podiatry visit. You have been asked to pay $35 copayment for podiatry visit. Podiatry visit falls within the Podiatry 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 a podiatry office visit provided on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive cardiovascular testing for hereditary
assessment services provided on March 9, 2021.

You asked the Plan to pay for the comprehensive cardiovascular testing for hereditary assessment services.
You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the
services rendered are not a covered benefit.

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 comprehensive cardiovascular testing for hereditary assessment testing at issue in this appeal 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 comprehensive cardiovascular testing for
hereditary assessment services provided on March 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips to get to all your doctor appointments. The Plan denied your request. The Plan says you have exhausted your Plan benefit for transportation.
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 20 one-way trips per year. 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that you rely on transportation for appointments to have MRI and follow-up done. The Plan denied your request. The Plan says the requested service is covered under the plan, but the requested amount exceeds the limit listed by the plan.

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 one-way trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR Section 422.2.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a 20% coinsurance for each surgical or observation room service you get at an outpatient hospital. You can find this information on page 75 of the Plan's 2021 Evidence of Coverage (EOC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat bilateral sacroiliac joint steroid injections.

You asked the Plan to pre-approve injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). You say that the enrollee needs this procedure for back pain relief. The Plan denied your request. The Plan says there is no documentation that the enrollee has benefited from prior injections in the same areas or has had a 6-week course of supervised physical therapy for the condition as per Plan guidelines.

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 injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that repeat SI joint injection is medically reasonable and necessary for the enrollee in this case. The case file does not contain sufficient documentation of failed conservative therapy. In addition, previous injections did not provide sustained relief of pain. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injection procedure for sacroiliac (SI) joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (27096) have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat bilateral sacroiliac joint steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to further pay for resin-based composite services (D2393) provided April 13, 2021.

You asked the Plan to further pay for resin-based composite services. You say that you would like to be reimbursed a greater amount based on the EOC. The Plan denied your request. The Plan says the claims has processed correctly as they made payment according to the Medicare allowable rate.

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 resin-based composite services with a 70% coinsurance (reduced to 50%) of the Medicare-allowable rate.

We looked at the file and Medicare rules. In this case, the Plan has reimbursed you $59.50 ($119.00 Medicare-allowable rated x 50% coinsurance). You are responsible for the additional amount that the provider is charging minus the cost share ($365.00 Total charge - $59.50 coinsurance). Based on this information, we decided that the Plan's rules for coverage of resin-based composite services have not been met. Therefore, we decided that the Plan does not have to further pay for resin-based composite services (D2393) provided April 13, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance service, basic life support, non-emergency transport (A0428), and the ground mileage (A0425) provided on April 15, 2021.
You asked the Plan to pay for the ambulance services. You say that the transportation was medically necessary. The Plan denied your request. The Plan says that transportation from a physician office to the skilled nursing facility (SNF) is not covered by Medicare.
We find that the Plan's rationale regarding the noncovered origin/destination is not applicable in this case.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 
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 to pay for the ambulance services. Our reviewer says that the ambulance services are medically necessary. Our physician reviewer found that the provided documentation indicates that the enrollee had a displaced fracture of lumbar vertebra. The reviewer found that the enrollee required ambulance services due to lumbar fracture and required monitoring enroute. Therefore, the reviewer has determined that the ambulance transportation services were medically reasonable and 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 ambulance services have been met. Specifically, the ambulance services were medically necessary. Therefore, we decided that the Plan has to pay for the ambulance service, basic life support, non-emergency transport (A0428), and the ground mileage (A0425) provided on April 15, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on April 18, 2021.

You asked the Plan to pay for the self-administered drug. You say that you do not know what drugs you were
given because you were in pain and could not breathe. The Plan denied your request. The Plan says self-administered
drugs are not covered in an outpatient hospital setting.

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 the self-administered drug
provided on April 18, 2021.

Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided May 8,
2021.

You asked the Plan to pay for the panoramic x-ray. You say that the service was necessary, and you would like
it covered. The Plan denied your request. The Plan says you have exceeded frequency limits for the panoramic
x-ray and therefore it is not covered.

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 the panoramic
x-ray when the services are medically necessary and reasonable.

We looked at the file and Medicare rules. The Plan provided documentation showing that a panoramic x-ray
was previously covered on January 29, 2021. Based on this information, we determined that the Plan's
frequency limit for coverage of the panoramic x-ray has been exceeded. Therefore, we decided that the Plan
does not have to pay for the panoramic radiographic image (D0330) provided May 8, 2021.