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

We decided that the Plan has to pre-approve the requested shank foot system with vertical loading pylon coded as L5987.
You asked the Plan to pre-approve the L5987 prosthetic foot. You say that the requested foot is medically necessary. The Plan denied your request. The Plan says that the notes from a power wheelchair evaluation in August 2021 show that the enrollee was approved for the wheelchair due to inability to perform daily living activities due to risk of falling.
The Plan follows Medicare rules. Medicare rules say that the advanced shank foot system (L5987) is covered for enrollees with a functional level of 3 or higher. 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 L5987 prosthetic foot. Our reviewer says that the documentation from the record supports that the enrollee meets criteria for the requested advanced prosthetic foot. Our physician reviewer found based on the medical records provided there is documentation that the enrollee meets criteria for the advanced K3 foot. Notes from the enrollee's treating provider dated 09/01/2021 clearly document the potential for functional level 3 activity once he is fitted with a prosthesis, irrespective of the fact that the enrollee has required a wheelchair for mobility after the amputation surgery. 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 L5987 prosthetic foot have been met. Therefore, we decided that the Plan has to pre-approve the requested shank foot system with vertical loading pylon coded as L5987.
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: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a screening colonoscopy (G0121).

You asked the Plan to pre-approve the colonoscopy. You say that the colonoscopy is medically necessary. The Plan denied your request. The Plan says that this procedure is only covered once every 10 years for non-high-risk members.

The Plan follows Medicare rules. Rules say that Medicare allows a screening colonoscopy for a non-high risk member to be covered once every 10 years. 

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 colonoscopy. Our reviewer says that the colonoscopy is medically necessary. Our physician reviewer found the enrollee underwent routine average-risk colon screening by colonoscopy in 2016 at which time a 10mm cecal polyp and a 4mm rectosigmoid polyp were removed. The enrollee's colon preparation was suboptimal. Standard of care warrants a repeat colonoscopy now on an accelerated recall schedule due to the enrollee's higher risk of missed colon lesions in 2016 because of her non-optimal colon prep. 

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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-approve a screening colonoscopy (G0121).

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815).

You asked the Plan to pre-approve PETCT scan. You say that the medical records provided support the necessity of the services in dispute The Plan denied your request. The Plan says the enrollee does not meet the criteria.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 PETCT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current guidelines would support a bone scan as a next step staging study and PET scan if this study is not diagnostic. Medicare coverage criteria as above have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PETCT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78815).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on June 23, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization 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 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 drug testing services provided on June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for treatment of non-pressure chronic ulcers including chemical cauterization and debridement provided on September 27, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for wound care services. You say that the services were rendered for medical necessity and patient care was provided as an urgent request to avoid wound complications. You say the physician performed the services in good will without requesting an authorization to avoid delaying care. The Plan denied your request. The Plan says enrollees are required to use doctors that are in-network with the Plan. The Plan also says out-of-network coverage is allowed for emergency services when no in-network providers are available.

However, the medical records reflect that the services were not an emergency and were routine in nature. The Plan states there are in-network doctors who could have provided the services. Therefore, the Plan denied your request for payment.

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 treatment of non-pressure chronic ulcers including chemical cauterization and debridement provided on September 27, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric care provided from March 5, 2021, to April 30, 2021.

You asked the Plan to pay for the inpatient psychiatric care. The Plan denied your request. The Plan says this request is not medically necessary because the records received show that the enrollee's condition had improved, and they are no longer a threat to themself or others.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient psychiatric care. Our reviewer says that this patient does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of March 5, 2021 forward and could have been treated in a lesser restrictive setting. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The patient was cooperative and compliant with medication. Our reviewer found that it did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. Our physician reviewer also found that it did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. 

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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric care provided from March 5, 2021, to April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urgent care visits you had on August 6, 2021, and August 10, 2021.

You asked the Plan to waive the copayments for the urgent care visits. You say that the urgent care staff told you that you didn't owe anything. You said that you ended up having to go to your primary care doctor. 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 $65 copayment per visit for urgent care services.

You have been asked to pay a $65 copayment per visit for the urgent care visits. These copayments apply regardless of the outcome of the visits. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the urgent care visits you had on August 6, 2021, and August 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a computed tomographic (CT) angiography of the chest provided on June 30, 2021.

You asked the Plan to waive the coinsurance for the CT angiography. You say that you feel that you should only have copayments for primary care and specialist visits. 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 a 20% coinsurance up to $75 per day for diagnostic radiology services.

You have been asked to pay $43.03, which is 20% of the allowed amount for the CT angiography. The CT angiography 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 coinsurance for a computed tomographic (CT) angiography of the chest provided on June 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on October 5, 2021.

You asked the Plan to pay for the dental service. You say that this service is necessary when a dental implant is completed. You also that this should not be considered a medical procedure. The Plan denied your request. The Plan says bone replacement graft 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 bone replacement graft is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on October 5, 2021.
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for physical therapy. We decided that the Plan does not have to waive the copayment for physical therapy.
You asked the Plan to waive the copayment for physical therapy. You say that you were told to go to physical therapy by your surgeon. The Plan says that the correct copayments have been applied.
We decided that the Plan has to reduce the copayment for physical therapy.
The Plan follows Medicare rules. Medicare rules say that you cannot be charged more than a $40 copayment for outpatient rehabilitation services. Therefore, we decided that the Plan has to reduce the copayment for physical therapy.
We also decided that the Plan does not have to waive the copayment for physical therapy.
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 $40 copayment for physical therapy. The total amount you are being asked to pay is $240 ($40 x 6 sessions = $240). Therefore, we decided that the Plan does not have to waive the copayment for physical therapy.
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 waive the copayment for an injection of an eye drug (67028), and the copayment for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina (92134) provided on September 24, 2021. We also decided that the Plan also does not have to waive the coinsurance for an injection of aflibercept (J0178) also rendered on September 24, 2021.

You asked the Plan to waive the copayment for an injection of an eye drug, and for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina. You also asked the Plan to waive the coinsurance for an injection of aflibercept.

You say that you were told the service was approved, never that your copayment was so high. You also say you are upset for receiving a high bill that you are not able to afford on your social security benefits. The Plan denied your request. The Plan says you were charged 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 $35 copayment for each Medicare-covered exam to treat an eye condition, a $65 copayment for each covered diagnostic procedure or test at a network doctor's office, and a 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay a $35 copayment for an injection of an eye drug. An injection of an eye drug falls within the Vision Care - Medicare-covered benefit category. You also have been asked to pay a $39.40 copayment, which is less than the $65 copayment for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina. The scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to pay $366.56 in coinsurance, which is 20% of the allowed amount for an injection of aflibercept ($1832.82 allowed amount x 20% coinsurance = $366.56). Injections of aflibercept fall within the Medicare Part B drug 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 injection of an eye drug (67028), the copayment for the scanning of computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral of the retina (92134), or the coinsurance for an injection of aflibercept (J0178) rendered on September 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on July 9, 2021, to July 15, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that these services were all part of one inpatient stay, and only the first copayment should apply. The Plan denied your request. The Plan says these claims were processed correctly, and the cost-sharing amounts were assessed in accordance with the enrollee's contract. Inpatient cost-share begins on day one each time the enrollee is transferred or admitted to a different inpatient facility or level of care.

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 $350 copayment for each of the first five days of an inpatient hospital stay. Inpatient cost-share begins on day one each time the enrollee is transferred to an inpatient facility. 

The enrollee has been asked to pay a $998.35 copayment for the inpatient hospital stay which exceeded five days. Documentation shows that on July 9, 2021, the enrollee was transferred and admitted to a new inpatient facility. Therefore, new cost sharing applies. The record also shows that at the time of this inpatient stay, the enrollee met their out-of-pocket maximum for the year, and as a result are being billed less than the full copayment. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. 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 waive the copayment for the inpatient hospital care provided on July 9, 2021, to July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skin biopsy procedure you had at an outpatient hospital facility on September 3, 2021.

You asked the Plan to waive the copayment for the skin biopsy procedure. You say that you were just in a tiny exam room for about 15 minutes while the skin biopsy was done. You believe that people should be made aware that they are going to be charged such a large copayment for just a short visit. 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 $350 copayment for outpatient surgery and other services at an outpatient hospital facility.

You have been asked to pay a $350 copayment for the skin biopsy procedure. The skin biopsy procedure falls within the outpatient surgery and other services at an outpatient hospital facility benefit category. This copayment applies regardless of how minor the procedure is or how long the procedure takes. 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 skin biopsy procedure you had at an outpatient hospital facility on September 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the specimen collection for severe acute respiratory syndrome Coronavirus (G2023) provided on January 6, 2021.
You asked the Plan to pay for the specimen collection. You say that you are an independent laboratory and do not see the enrollee directly. You also say that you only receive the specimens from the enrollee's referring physician to test and report your findings. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the specimen collection for severe acute respiratory syndrome Coronavirus (G2023) provided on January 6, 2021.