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

We decided that the Plan does not have to waive the coinsurance for the bandages (A6456 and A6454), and skin barrier (A5120), provided on May 18, 2021.
You asked the Plan to waive the coinsurance for the bandages and skin barrier. You say that the items should be covered. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the bandages and skin barrier. the bandages and skin barrier 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 the bandages (A6456 and A6454), and skin barrier (A5120), provided on May 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) provided October 13, 2021.
You asked the Plan to waive the copayment for the aspiration and/or injection of large joint or joint capsule. You say that you do not feel you owe any additional amount for the service. The Plan denied your request. The Plan says the copayment was 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 $390 copayment for nuclear medicine services.
You have been asked to pay $253.87 for the aspiration and/or injection of large joint or joint capsule. This service falls within the nuclear medicine services benefit category. This means that you have been asked to pay less than or equal to 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 arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance (20610) provided October 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 25, 2021.

You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. 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 physician services provided to the enrollee on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 23, 2021 by an out-of network
(OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services 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.
Therefore, we decided that the Plan does not have to pay for the office visit provided on April 23, 2021 by an
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a refraction (eye exam) (92015) provided on June 22, 2021.

You asked the Plan to pay for an eye exam. You say that you did not know this would not be covered. The Plan denied your request. The Plan says you signed an agreement to pay for this non-covered service.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by in-network optometrists. 

We looked at the file and the Plan's rules. The records show that this service was provided by an ophthalmologist rather than an optometrist. Based on this information, we decided that the Plan's rules for coverage of an eye exam have not been met. Therefore, we decided that the Plan does not have to pay for a refraction (eye exam) (92015) provided on June 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear bone test provided June 16, 2021.

You asked the Plan to waive the copayment for the nuclear bone test. You say that you had a nuclear bone test and at the office had to pay $15.00. You did not stay overnight so you do not understand why your copayment is $360.00. The Plan denied your request. The Plan says the 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 $360 copayment for nuclear medicine services in an outpatient hospital.

You have been asked to pay $360 copayment for the nuclear bone test. The nuclear bone test 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 the nuclear bone test provided June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the office visit (99214), the compounded drug (J7999), and the electronic analysis of a programmable, implanted pump for intrathecal or epidural drug infusion (62369) provided on July 28, 2020.

You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services 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 $25 copayment for provider and professional services provided at a specialist's office. Additionally, you pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay $69.42 which includes a $25 copayment for the provider services rendered at a specialist's office and $44.92 (Plan allowed amount of $222.10 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 adjust the cost share for the office visit (99214), the compounded drug (J7999), and the electronic analysis of a programmable, implanted pump for intrathecal or epidural drug infusion (62369) provided on July 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to approve continued inpatient psychiatric services beyond October 22, 2021.

You asked the Plan to approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

We looked at the file and Medicare rules. There is no documentation to support that the continued psychiatric services meet the Medicare criteria for coverage. The Plan requested records for the enrollee's inpatient care
but a response was not received. 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 approve continued inpatient psychiatric services beyond October 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient rehabilitation facility
(IRF) services provided from May 21, 2021, to June 7, 2021.

You asked the Plan to waive the copayment for the IRF services. You say that you went to this facility before
and were not charged previously. The Plan denied your request. The Plan says that the copayment was 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 $150
copayment for each day in inpatient rehabilitation for the first five days.

You have been asked to pay a $1,500 copayment for the IRF services. The IRF services falls within the
inpatient rehabilitation for the first five days 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 acute inpatient rehabilitation facility (IRF) services provided from May 21, 2021, to June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the oral exam you had on June 24, 2021.

You asked the Plan to pay for the oral exam. The Plan denied your request. The Plan says that the benefit limit has been exceeded.

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. The Plan argues that only one oral exam is covered every 6 months, and that the requested exam exceeds the benefit limit. However, the Plan does not provide documentation showing that an oral exam was covered within 6 months prior to the requested exam. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the oral exam you had on June 24, 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 domiciliary or rest home visit for the evaluation and
management of an established patient (99335) rendered by the out-of-network (OON) provider on February 23,
2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established
patient (99335) rendered by the out-of-network (OON) provider on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite Meter Kit.

You asked the Plan to pre-approve the kit. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says they have not seen any indication to why you cannot use a Foracare Meter and test strips.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. Documentation was not provided to show that you have tried and failed or cannot tolerate the following formulary alternative: Foracare Meter. Based on this information, we decided that Medicare rules for coverage of the kit have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite Meter Kit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a bath/shower chair (E0240), a raised toilet seat (E0244), toilet rails (E0243), bedside rails (E0305), a cast protector (A9999), and applicable sales tax (S9999) provided on December 22 to December 30, 2020.

You asked the Plan to pay for a bath/shower chair, a raised toilet seat, toilet rails, bedside rails, a cast protector, and applicable sales tax. You say that the items at issue were necessary to avoid fall risk. The Plan denied your request. The Plan says the items at issue are not covered under Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for a bath/shower chair (E0240), a raised toilet seat (E0244), toilet rails (E0243), bedside rails (E0305), a cast protector (A9999), and applicable sales tax (S9999) provided on December 22 to December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September 9, 2021, onward.

You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued inpatient psychiatric care is medically necessary, and you continue to require injections for behavioral issues and are not yet stable enough to be discharged to a lower level of care The Plan denied your request. The Plan says as of September 9, 2021, you no longer met criteria for psychiatric services at the inpatient level.

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 pre-approve continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at an inpatient level is appropriate in this case. Our physician reviewer found that you were admitted to the acute inpatient psychiatric hospitalization on July 14, 2021 with Schizoaffective Disorder Bipolar Type. Based upon review the records provided it was not expected that you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. 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. 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 your condition or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 9, 2021 forward and could have been treated in a lesser restrictive setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September 9, 2021, onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery operated portable Bilevel positive airway pressure (BiPAP) device for the enrollee.

You asked the Plan to pre-approve a battery operated portable BiPAP. You say that this is medically necessary. The Plan denied your request. The Plan says that you were provided a BiPAP.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The file shows that the enrollee has a standard BiPAP. A standard BiPAP serves the same purpose as a battery operated portable BiPAP. Therefore, we decided that the Plan does not have to pre-approve a battery operated portable Bilevel positive airway pressure (BiPAP) device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 17, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 17, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a sexually transmitted disease screening (87491, 87591) provided on February 9, 2021.

You asked the Plan to pay for a sexually transmitted disease screening. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with a diagnosis that indicates this was a screening service.

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, a sexually transmitted disease screening, 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 a sexually transmitted disease screening (87491, 87591) provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (J0475) provided February 8, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code J0475 is not supported in the medical record. Specifically, the claim was not billed with a valid NPI number. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (J0475) provided February 8, 2021.