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

 We decided that the Plan does not have to waive the copayment for the abdominal ultrasound (76700) provided on July 2, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you received similar ultrasound services in previous years and were asked to pay less on those occasions. You do not understand reason for the change in cost. The Plan denied your request. The Plan says in previous years, ultrasounds required 20% coinsurance. As of your 2020 contract however, ultrasounds require a $160 copayment. This information was explained in the Annual Notice of Changes for 2020, and there was no change in the cost-sharing amount for ultrasounds from 2020 to 2021. Your 2021 contract states that radiological diagnostic services obtained in-network require a $160 copayment. Therefore, this claim was processed correctly, and your cost-sharing amount was assessed in accordance with your contract.  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 $160 copayment for Medicare-covered radiological diagnostic services.   You have been asked to pay a $132.17 copayment for the ultrasound. An ultrasound falls within the Medicare-covered radiological diagnostic 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 the abdominal ultrasound (76700) provided on July 2, 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 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 the enrollee does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy and occupational therapy, his rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility.  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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.  You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 skilled nursing facility services. 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.  The enrollee is ambulating more than 100 feet and tending to daily activity with minimal supervision.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the albuterol inhaler provided in an outpatient setting on July 16, 2021.

You asked the Plan to pay for the self-administered drug. You say that this should be covered. The Plan denied your request. The Plan says the albuterol inhaler is considered a self-administered drug. The Plan says that self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the albuterol inhaler is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the albuterol inhaler provided in an outpatient setting on July 16, 2021.

Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital discharge day management service provided on September 11, 2020.  You asked the Plan to pay for the hospital discharge day management service. The Plan denied your request. The Plan says this claim will need to be submitted to Original Medicare for consideration of payment.  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 hospital discharge day management service provided on September 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from June 22, 2021, to June 30, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you feel this charge is not correct or fair, and you have never been billed this much for a hospital room. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. You are responsible for $298 for each of the first seven days of an inpatient hospital stay.  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 $298 copayment for each of the first seven days of an inpatient hospital stay. There is a $0 copayment for additional days. You have been asked to pay a $2,086 copayment for the inpatient hospital stay which exceeded seven days. ($298 x 7 days = $2,086). 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 inpatient hospital admission and services provided from June 22, 2021, to June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on  July 1, 2021.  You asked the Plan to waive the copayment for the ambulance services. You say that you had to be transported between two facilities so that you could get a test.  You expected a transport van, but an ambulance was sent instead. You stated that you were told that the hospital would take care of the transportation. 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 $250 copayment per trip for ambulance services.        You have been asked to pay a $250 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. 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 you received on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device and supplies (codes E0675 and E0673) provided on March 31, 2021.  You asked the Plan to pay for the pneumatic compression device and supplies. You say that this device is medically necessary for this patient and it is not considered experimental/investigational. The Plan denied your request. The Plan says this specific device is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that pneumatic compression devices coded as E0675 are not covered by Medicare.In addition, the rules say that E0673 is only covered when billed with a covered pneumatic compression device.  Because E0675 is not a covered device, this supply is not covered either. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device and supplies have not been met.  Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and supplies (codes E0675 and E0673) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for procedure code 28899 provided on June 4, 2021.  You asked the Plan to pay for procedure code 28899. You say that you have provided medical records to support the billing. The Plan denied your request. The Plan says that this code was originally denied because the service was not supported by the records.  The Plan then advised that on reconsideration, they failed to meet their time frame for review and they submitted the case to us.  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. Specifically, there is absolutely no documentation about why the Plan denied this code in the case file submitted to us other than a generic one-line statement that the 'code wasn't supported.'  The Plan has not explained how the code wasn't supported or what medical records they reviewed when determining there was a deficiency.  They have provided no evidence of how this code was reviewed or who at their organization reviewed the records.  The burden is on the Plan to provide why its denial is appropriate, and they have failed to do so in this case. the plan has to pay for procedure code 28899 provided on June 4, 2021. Therefore, we decided that the Plan has to pay for procedure code 28899 provided on June 4, 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: Favorable

We decided that the Plan has to waive the deductible charged for the medical services provided on January 19, 2021.

You asked the Plan to waive the deductible charged for the medical services. You say that you did not have a number of the services that appeared on your bill. The Plan denied your request. The Plan says that you were assessed this deductible appropriately.

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 basis of your appeal is that you claim you were billed for services never received. The Plan had an obligation to obtain the medical records to determine if these services were billed correctly. The Plan failed to obtain these medical records, even though the provider is a network Provider with the Plan. That means that these records are in the Plan's control. Without these records, we cannot determine if the services billed were appropriate. It is the Plan's burden to show that their assessment of this deductible is correct, and without these records, they have failed to do so. Therefore, we decided that the Plan has to waive the deductible charged for the medical services provided on January 19, 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: 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 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
May 28, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. 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 out of network physician services provided to the
enrollee on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral complete series x-ray provided on May 26, 2021.

You asked the Plan to pay for the intraoral complete series x-ray. You say that the provider said they were forced to do two panoramic films and charged you $30. You say that you were assured by this office that you would not be charged any copayment fees and the $145 bill should be managed by the Plan. The Plan denied your request. The Plan says reimbursement has already been issued for a full mouth x-ray.

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, you also have a maximum benefit of one complete series or panoramic x-ray every three years. The Plan paid for the complete series x-ray provided on May 24, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the intraoral complete series x-ray provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unspecified preventive procedure provided on June 28, 2021.  You asked the Plan to pay for the unspecified preventive procedure. You say that you did not choose to keep this dental company as you have a slow healing plan for your mouth and you already paid $100. You say that the copayment amount should be reviewed, and payment should be submitted. The Plan denied your request. The Plan says the additional extraction will be paid and the unspecified preventive procedure remains denied as a non-covered service.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive procedure provided on June 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Droxidopa capsule.  You asked the Plan to pre-approve Droxidopa capsule. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Droxidopa capsule.   Benefits for Droxidopa capsule may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a cardiovascular risk assessment panel provided to the enrollee on August 26, 2020.  You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  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 pay for this testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this test is a genetic screening for cardiovascular risk factor screening test in which 62 genes are assessed using genomic DNA. This test is not approved by the FDA. There is no evidence to support the results of this testing will contribute to the enrollee's course of treatment. We looked at this physician's review, the file, and Medicare rules.  Based on this information, we decided that Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular risk assessment panel provided to the enrollee on August 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for an adjunctive pre-diagnostic test (D0431) provided by a participating provider on July 28, 2021.  You asked the Plan to pay for an adjunctive pre-diagnostic test. You say that the office failed to inform her that this wasn't going to be covered. You say that you should not have to pay for this. The Plan denied your request. The Plan says the dental services that were provided are 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 adjunctive pre-diagnostic test (D0431) provided by a participating provider on July 28, 2021.