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

We decided that the Plan does not have to waive the copayments for the hip x-ray and the office visit you had with an orthopedic surgeon on April 23, 2021.

You asked the Plan to waive the copayments for the x-ray and the office visit. You say that the office visit copayment should cover the x-rays. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the x-ray, the allowed amount for this service ($43.48) is less than your copayment obligation, so you are responsible for the full allowed 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 $50 copayment for x-rays in a provider's office and a $35 copayment for visits with a specialist.

You have been asked to pay a $50 copayment for the x-ray and a $$35 copayment for the office visit. There is no provision in your contract that says that all services performed during an office visit are included in the copayment for the office visit. You received a separate and distinct x-ray service, so an x-ray copayment applies. 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 hip x-ray and the office visit you had with an orthopedic surgeon on April 23, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care provided on March 9, 2021.
You asked the Plan to pay for initial hospital care. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 2, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for initial hospital care provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician visit and the glucose test provided on April 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician visit and the glucose test. You say that the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 requested provider in this case is not a network provider with the Plan. 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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the physician visit and the glucose test provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance service, basic life support, nonemergency
transport provided on March 31, 2021.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says the claim was processed according to your Evidence of Coverage, which states that the member has a
$290 copay for services provided by an in-network non-emergency ambulance used for ground transportation.
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 $290
copayment for Ambulance Services.
You have been asked to pay $290 copayment for the ambulance service, basic life support, non-emergency
transport.
The ambulance service, basic life support, non-emergency transport falls within the Ambulance Services
benefit category. This means that you have been asked to pay the correct amount based on your contract with
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for ambulance service, basic life
support, non-emergency transport provided on March 31, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve a 40mg dose of Sandostatin Lar Depot.
You asked the Plan to pre-approve a 40mg dose of Sandostatin Lar Depot. You say that this is medically
necessary. The Plan denied your request. The Plan says that this dosage is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 a 40mg dose of Sandostatin Lar Depot.
Our reviewer says that the requested medication is supported in this case. Our physician reviewer found a
40mg dose of Sandostatin Lar Depot is FDA-approved for long-term treatment of severe diarrhea and flushing
episodes associated with carcinoid syndrome in patients with metastatic gastroenteropancreatic neuroendocrine
tumors. It is safe, effective, and otherwise reasonable and necessary for this enrollee.
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 40mg dose of Sandostatin Lar Depot have been met. Therefore, we decided
that the Plan has to pre-approve a 40mg dose of Sandostatin Lar Depot.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 28, 2020.

You asked the Plan to pay for laboratory services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 laboratory services provided on December 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy consisting of hot or cold pack application (97010, 47 units).
You asked the Plan to pre-approve the hot or cold pack applications. You say that this service is medically necessary. The Plan denied your request. The Plan says all other therapy services were approved but the requested code is not separately payable and is not considered a skilled service under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that regardless of whether code 97010 is billed alone or in conjunction with another therapy code, this code is never paid separately. Furthermore rules state that hot or cold packs (including ice massage) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a therapist.
We looked at the file and Medicare rules. The requested CPT code is not separately payable and is not covered. Based on this information, we decided that Medicare rules for coverage of the hot or cold pack applications have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy consisting of hot or cold pack application (97010, 47 units).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that you are unable to use the crank to
go up and down. The Plan denied your request. The Plan says total electric hospital beds are not covered by
Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium.
You asked the Plan to pre-approve computed tomography, heart, without contrast material, with quantitative
evaluation of coronary calcium (75571). You say that this service is to further assess the risk of coronary artery
disease and guide decision making of the statin dose. The Plan denied your request. The Plan says imaging to
measure the amount of calcium deposits in the blood vessels that supply blood to your heart muscle is not a
covered 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, computed tomography, heart, without contrast material, with quantitative
evaluation of coronary calcium (75571), is being 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 pre-approve
computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency oscillation device (E0483).
You asked the Plan to pre-approve the high frequency oscillation device. You say that that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria as she does not have a qualifying diagnosis.
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve high frequency oscillation device (E0483).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on February 17, 2021.
You asked the Plan to pay for ambulance services. You say that you contacted emergency medical services (EMS) because your blood pressure was elevated, and your blood sugars were abnormal. You say when you were asked if you wanted to go to the emergency room, EMS advised you that you were okay after rendering services. The Plan denied your request. The Plan says that per Medicare, the ambulance benefit is a transportation benefit and without a transport there is no payable service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance services provided on
February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) stay you had from April 3, 2021, to April 23, 2021.
You asked the Plan to waive the copayment for the SNF stay. You say that you are in a wheelchair and your live alone and you cannot pay this bill. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility care.
Records show that you were in one SNF from March 29, 2021, to April 3, 2021. You were then transferred to another SNF where you stayed from April 3, 2021, to April 23, 2021. Both stays totaled 25 days. In accordance with your contract, you were not charged a copayment for the first 20 days. For the remaining 5 days, you were assessed a copayment of $184 per day, for a total of $920. However, at the time of these services, you only had $798.33 remaining on your out-of-pocket maximum, so that is all you are being charged for these services. 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 skilled nursing facility (SNF) stay you had from April 3, 2021, to April 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you received on January 20, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you have never had to pay a copayment in the past. In addition, you say that your contract says that you have a $0 copayment for bloodwork. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that in 2020, certain copayments were waived due to programs in place as a result of the Coronavirus pandemic. Those programs are not in place for 2021, so the copayment applies.
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 copayment for lab services. Medicare considers the services you received to be lab services as they appear on the Medicare Clinical Lab Fee schedule. In addition, the provision in your Evidence of Coverage that you cite claiming that there is no copayment for 'bloodwork' is not what the contract actually says- your contract says that you pay $0 for blood.
Blood means the actual supply of blood, not the testing of your blood. It is not a provision regarding bloodwork', but of the blood itself. That is why that provision doesn't apply to the services you received. You have been asked to pay a $20 copayment for the lab services. 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 lab services you received on January 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tub grab bar (E0241).
You asked the Plan to pre-approve a grab bar. You say that the grab bar is medically necessary. The Plan denied your request. The Plan says this item is not covered.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a tub grab bar (E0241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy drugs you received from April 20, 2021, to April 22, 2021.

You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you cannot afford this cost sharing because you are on a fixed income. 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, including chemotherapy drugs.

You have been asked to pay 20% coinsurance for the chemotherapy drugs. 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 chemotherapy drugs you received from April 20, 2021, to April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) provided May 22, 2021

You asked the Plan to pay for the office visit. You say that you were dissatisfied with how you were treated. You feel that you should not have to be changed for non-covered codes. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) provided May 22, 2021

The Qualified Independent Contractor (QIC) read your letter and knows that you may have a quality of care concern. The QIC cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on March 4, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for ambulance services. You have been asked to pay a $395 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on March 4, 2020.
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 you had a fall, and you need to learn how to balance yourself again. You also say the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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.

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.