Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filing (D2392) and limited oral evaluation (D0140) provided from April 8, 2021, to June 17, 2021.
You asked the Plan to pay for the dental services. You say that you have dental coverage up to $2,000. You also say that you do not understand why the charges are being denied when your policy clearly states that dental is included. The Plan denied your request. The Plan says 2 fillings are covered per calendar year. The Plan says that the frequency limit has been exceeded. The Plan also says that limited oral evaluation 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 and fillings are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for 2 fillings that you received on January 14, 2021. Additionally, the limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the filing (D2392) and limited oral evaluation (D0140) provided from April 8, 2021, to June 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cladribine (J9065).
You asked the Plan to pre-approve cladribine. You say that this is medically necessary. The Plan denied your request. The Plan says this use is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 cladribine. Our reviewer says that the requested use of cladribine is not supported. Our physician reviewer found this use of cladribine is not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis, and it is not supported by one of the major drug compendia or by clinical research. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cladribine have not been met. Therefore, we decided that the Plan does not have to pre-approve cladribine (J9065).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99347) provided on October 15, 2019.
You asked the Plan to pay for the home visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the records do not indicate that the physician or non-physician practitioner were present.
The Plan must follow Medicare rules. Medicare rules say that coverage of services incident to the professional services of a physician or non-physician practitioner (NPP) is limited to situations in which there is direct supervision of auxiliary personnel. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home visit have not been met. Specifically, the record does not indicate that the physician or NPP were present in the home when the services were rendered. Therefore, we decided that the Plan does not have to pay for the home visit (99347) provided on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for inpatient hospital services you received from June 22, 2021, to June 27, 2021.
You asked the Plan to reduce the copayment for the inpatient hospital services. You say that you thought when you signed up for this Plan that it said if you stayed in the hospital overnight, you would have a copayment of either $650 or $750. 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 $275 copayment per day for days 1-6 for inpatient hospital services. Records show that you were in the hospital for five days. You have been asked to pay a 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 reduce the copayment for inpatient hospital services you received from June 22, 2021, to June 27, 2021.copayment of $275 per day, for a total of $1375. This means that you have been asked to pay the correct amount based on your
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for physician services. We decided that the Plan does not have to fully waive the copayment for physician services.

You asked the Plan to waive the copayment for physician services. You say that the doctor would not go over your colonoscopy results unless you came into the office. You say there is no charge for the colonoscopy, and if there was a charge for the results, you should have been told. The Plan says that you have been asked to pay the correct cost sharing amount.

We decided that the Plan has to reduce the copayment for physician services.

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 about whether the provider is a Level 1 specialist or not. Therefore, we decided that the Plan has to reduce the copayment to the lesser charge for specialist physician services.

We also decided that the Plan does not have to fully waive the copayment for physician services.

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 at least $35 copayment for specialist physician services. Therefore, we decided that the Plan does not have to fully waive the copayment for physician services.

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 waive the coinsurance for the Orthovisc injection you received on May 6, 2021.

You asked the Plan to waive the coinsurance for the Orthovisc injection. You say that you have been getting these injections for six years and you have never had to pay for them before. You believe this cost is too high. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs. 

You have been asked to pay 20% coinsurance for the Orthovisc injection. The Orthovisc injection falls within the Medicare Part B drugs 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 Orthovisc injection you received on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 4, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and the physician said you would not owe a copayment. 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 $45 copayment for specialist visits. You had a specialist visit on June 4, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $45 copayment. 

You have been asked to pay a $45 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on June 4, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on April 23, 2021.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. Specifically, the documentation does not support that the 3 key components within the constraints imposed by the urgency of the enrollee's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the enrollee's and/or family's needs. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015), provided on May 20, 2021.
You asked the Plan to pay for the routine vision services. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the eye exam (92014) and refraction (92015), provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the office visit provided on April 7, 2021.
You asked the Plan to reimburse you for the office visit. You say that this provider provided you with the best care possible so you should be reimbursed at least the Medicare allowed amount. The Plan denied your request. The Plan says this provider it not certified for Medicare therefore the cost of the services cannot be reimbursed.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the office visit provided on April 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded as 76770 provided on November 30, 2020.

You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is a duplicate claim to what has already been paid.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We find that CPT code 76770 is not supported in the medical record. Specifically, the record indicates that this is an exact duplicate of another claim that has been processed and paid. Based on this information, we decided that Medicare rules for coverage of the ultrasound services have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound services coded as 76770 provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on April 7, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because no one could treat your problem. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolaris prostate cancer assay.

You asked the Plan to pre-approve a Prolaris prostate cancer assay. You say that the enrollee has prostate cancer, and the requested test is needed in order to determine the best course of treatment. The Plan denied your request. The Plan says the requested testing is not covered because the records show that the enrollee has high-risk disease with a Gleason score of 10 with predominant Grade 5 disease.

The Plan follows Medicare rules. Medicare rules say that the Prolaris assay is covered when certain clinical conditions are met. 

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 a Prolaris prostate cancer assay. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is a 76-year-old man with prostate cancer. The Biopsy Test Request Form documents a highest Gleason score of 5 for primary grade and 5 for secondary grade, for a Gleason score of 10. The enrollee does not have favorable intermediate-risk disease, defined by the NCCN as predominant Gleason grade 3, percentage of positive cores less than 50%, and no more than 1 NCCN intermediate-risk factor. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Prolaris prostate cancer assay have not been met. Therefore, we decided that the Plan does not have to pre-approve a Prolaris prostate cancer assay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services received on April 7, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the provider was out-of-network.
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 services when the services are provided by a network provider. The rendering provider is not in the plan's dental network. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for dental services received on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a duplex scan provided on March 11, 2021.
You asked the Plan to waive the deductible for a duplex scan. You say that you paid your deductible on January 8, 2021 and should not be responsible for the 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. Your contract with the Plan says that there is a $225 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. You received a duplex scan on March 11, 2021. The record shows that the services you received on January 8, 2021 processed with coinsurance charges, not a deductible. Therefore, the $225 deductible had not been met at the time a duplex scan was received on March 11, 2021 and you are responsible to pay the allowed amount of $133.71. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $225 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies.
This cost sharing is a contractual obligation that had not been met at the time a duplex scan was received on March 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a duplex scan provided 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 IRF admission is medically necessary. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing and physical therapy services.
You asked the Plan to pre-approve the requested services. You say that you still need help. The Plan denied
your request. The Plan says you are unable to fully participate in therapy and your wounds have healed.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 requested services. Our physician
reviewer found that the records do not show that skilled nursing services are required to provide services in
order to improve your condition, or to establish a maintenance program to maintain your condition or prevent
deterioration. There is no complex wound care. Your condition is chronic and stable. You have been educated
on wound care, medications, and disease management. The records do not show that skilled therapy services
are required to provide services in order to improve your level of function, or to establish a maintenance
program to maintain your level of function or prevent deterioration. A written exercise program was given, and
bed mobility skills were reviewed. You do not require ongoing skilled therapy.
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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve home health nursing and physical therapy services.