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

We decided that the Plan does not have to waive the copayment for the SNF stay provided from May 21, 2021, to May 31, 2021.
You asked the Plan to waive the copayment for the SNF stay. You say that you are appealing this claim. The Plan denied your request. The Plan says you have been asked to pay 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 $0 copayment for each Medicare-covered stay from days 1 to 20 and a $20 copayment for each Medicare-covered stay from days 21 to 100. You have been asked to pay a $220 copayment for SNF days 21 to 31. ($20 x 11 days = $220). The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows SNF days 1 to 20 were from March 31, 2021, to April 20, 2021, which applied a $0 copayment. 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 skilled nursing facility (SNF) stay provided by Victoria Nursing & Rehabilitation Center from May 21, 2021, to May 31, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve Cardionet Interpretation (93228).
You asked the Plan to pre-approve Cardionet Interpretation. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show why a shorter test would not be sufficient.
The Plan follows Medicare rules. Medicare rules say that Medicare coverage for real-time, outpatient cardiac telemetry is limited to patients who have demonstrated a specific need for this type of cardiac telemetry service as detailed in the 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 Cardionet Interpretation. Our reviewer says that the requested testing is medically necessary. Our physician reviewer found that the records show that you have known, but infrequent, paroxysmal atrial fibrillation and are maintained on a beta blocker and anti-coagulation therapy. You have not had symptomatic recurrence lately. Although you are on anti-coagulation treatment, you have not had an assessment of your atrial fibrillation burden which may affect further therapy, especially if there is any intolerance of the anti-coagulation. As you are currently in sinus rhythm as well, a short term (24-48 hour monitor) is unlikely to provide sufficient information as to the atrial fibrillation burden and prolonged monitoring of 2-4 weeks duration is reasonable and indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cardionet Interpretation have been met. Therefore, we decided that the Plan has to pre-approve Cardionet Interpretation (93228).
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: 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 these services are medically necessary. The Plan denied your request. The Plan says that your needs may be safely met in a skilled nursing facility.
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. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for hemarthrosis of the knee and
anemia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically reasonable
and necessary. The Plan denied your request. The Plan says this procedure is considered
experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S9502 provided
from January 8, 2021, to January 12, 2021.
You asked the Plan to pay for the home infusion therapy services. 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 payable.
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 S9502 is not supported in the medical record. Specifically, this code has a status code
of "I." A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy services coded S9502 provided from January 8, 2021, to January
12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment applied to emergency room services provided on May 21, 2021.
You asked the Plan to waive the copayment applied to the emergency room services. You say that you went to the emergency room believing you were having a heart attack. You say that you are a heart patient and have a family history of bad heart health. The Plan denied your request. The Plan says the copayment was appropriately applied 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 $75 copayment for Medicare-covered emergency room visits. You have been asked to pay a $75 copayment for the emergency room services. The emergency room services fall within the Medicare-covered 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 applied to emergency room services provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on May 18, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you want the Plan to pay for the service at issue. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210) provided on May 18, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on
March 15, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 $5 copayment for diagnostic lab services and diagnostic procedures. You have been asked to pay a $5 copayment for the laboratory services provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services provided on March 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic services provided on May 8, 2020.
You asked the Plan to pay for the services provided. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says the claim was received past the allowed timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services at issue was not filed until May 21, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the orthopedic services provided on May 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 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 are not payable 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 the laboratory services are not supported in the medical record. Specifically, if a laboratory
procedure produces multiple reportable test results, only a single code shall be reported for the procedure. If
there is no code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure
code with a single unit of service. Review of the file shows that more than one procedure code was billed for
the services rendered. Based on this information, we decided that Medicare rules for coverage of the laboratory
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services
provided on May 4, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on May 4, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network (OON) provider on
May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and intraoral - periapical first radiographic image (D0220) provided June 7, 2021.
You asked the Plan to pay for the limited oral exam, tooth extraction and intraoral x-rays. You say that you couldn't wait any longer for an appointment with a network provider. The Plan denied your request. The Plan says services provided out-of-network are 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 tooth extractions and intraoral x-rays when the services are rendered by a participating provider.
We looked at the file and Medicare rules. In this case the services were provided by an out-of-network provider. Based on this information, we decided that the Plan's rules for coverage of the tooth extraction and intraoral x-rays have not been met. Though the Plan offers coverage in excess of Medicare coverage, the limited oral exam is not a covered service. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and intraoral - periapical first radiographic image (D0220) provided June 7, 2021.
Your complaint about the length of time to get an appointment with a network provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement of the copayment for the inpatient skilled nursing facility (SNF) care provided from January 1, 2021, through January 31, 2021.
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 $0 per day, for days 1-20 and $178 per day, for days 21-100 for each skilled nursing facility (SNF) stay.
You have been asked to pay $2,314 ($178 copayment x 13 days) for the inpatient skilled nursing facility care 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 issue reimbursement of the copayment for the inpatient skilled nursing facility (SNF) care provided from January 1, 2021, through January 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central
venous catheter services coded 36556 and the fluoroscopic guidance services coded 77001 provided on March
12, 2021.
You asked the Plan to pay for the insertion of non-tunneled centrally inserted central venous catheter services
and the fluoroscopic guidance services. 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 separately payable.
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, we have confirmed that code 36556
for the insertion of non-tunneled centrally inserted central venous catheter services has a bundled relationship
with code 36558 and cannot be paid as billed. We have confirmed that code 77001 for the fluoroscopic
guidance services has a bundled relationship with code 37248 and cannot be paid as billed. These codes cannot
be paid as separate line items. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted
central venous catheter services coded 36556 and the fluoroscopic guidance services coded 77001 provided on
March 12, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on March 1, 2021, and March 8, 2021.
You asked the Plan to waive the copayment for the laboratory work. You say that you do not understand why a blood draw at home has a $5 copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $5 copayment for diagnostic laboratory services and diagnostic procedures and tests (per day, per facility). This excludes basic and advanced diagnostic imaging services. You have been asked to pay a $5 copayment for the laboratory work on each date of service. The laboratory work 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 laboratory work provided on March 1, 2021, and March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Invacare Solace Performance Mattress (E1399), to be provided by a non-preferred provider.
You asked the Plan to pre-approve an Invacare Solace Performance Mattress. You say that the item is medically necessary. The Plan denied your request. The Plan says you do qualify for a Type I mattress. However, the specific mattress being requested by is not available via the preferred vendor. It is not clear why this specific model is requested, but we will authorize a Type I mattress via the preferred vendor. The specific model requested is not covered as it cannot be determined to be medically necessary to be substituted for the standard Type I.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an Invacare Solace Performance Mattress (E1399), to be provided by a non-preferred provide
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), provided on March 23, 2021.
You asked the Plan to pay for a limited oral evaluation. You say that you do not agree with this denial. The Plan denied your request. The Plan says this is not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on June 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say
that you were not aware that the treating provider is OON. The Plan denied your request. The Plan says these services were rendered by an OON provider and are not covered under your benefit program.
The Plan also says that there were no call logs on file prior to these services being rendered showing a list of in-network providers was requested or to verify the treating provider's network status.
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 requested items or services are not covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on June 18, 2021 by an out-of-network (OON) provider.