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

 We decided that the Plan does not have to waive the copayment for telehealth services provided on July 9, 2021.  You asked the Plan to waive the copayment for telehealth services. You say that you should not have a copayment for telehealth services but the provider is billing you anyways. 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 $0 copayment for telehealth services provided by a primary care physician and a $50 copayment for telehealth services provided by a specialist.  You received telehealth services with a specialist on July 9, 2021. Therefore, you are responsible to pay the $50 copayment.    You have been asked to pay a $50 copayment for telehealth services. Telehealth services fall 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 telehealth services provided on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for debridement provided from August 6, 2021, to August 20, 2021.  

You asked the Plan to waive the copayments for debridement. You say that you had your leg wrapped but it got destroyed by diagnostic testing so you had to have it redone multiple times. 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 $40 copayment for specialist visits.  

You received debridement at a specialist's office from August 6, 2021, to August 20, 2021, for a total of 3 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 3 (specialist services) = $120.    

You have been asked to pay the total copayment amount of $120 for debridement. Debridement 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 copayments for debridement provided from August 6, 2021, to August 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 minutes.  You asked the Plan to pay for the therapeutic services. You say that please find the attached medical records required to reprocess the denied claim. The Plan denied your request. The Plan says the code is not appropriate for the service 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.  In this case, the CPT Code Manual definition of code 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.  We find that CPT code 97110 is not supported in the medical record. Specifically, the records indicate that the service is performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code (G0157) for the billed service. Based on this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedure, on one or more areas, each lasting 15 minutes.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a positron emission tomography (PET) scan provided on September 24, 2021.  You asked the Plan to waive the copayment for a PET scan. You say that no one explained that there would be a copayment for this service, and you felt the test was unnecessary. The Plan denied your request. The Plan says the service was provided and the proper copayment was applied.  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 $325 copayment for Medicare-covered diagnostic radiology services that are not ultrasounds.     You have been asked to pay a $325 copayment for a positron emission tomography (PET) scan. a PET scan 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 PET scan provided on September 24, 2021.   Your complaint about unnecessary services provided 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deep sedation/general anesthesia services (D9222 and
D9223) provided on October 11, 2021.
You asked the Plan to pay for the deep sedation/general anesthesia services. You say that you were not aware
that certain anesthesia was not covered under your plan. You also say that you would like the Plan to cover the
charges as a one-time exception. The Plan denied your request. The Plan says these services are not covered
expenses under your dental plan. The Plan also says that you contacted the Plan prior to this date of service and
were advised that anesthesia is not covered under your dental plan.
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 deep
sedation/general anesthesia services (D9222 and D9223) provided on October 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 7, 2021, to September 15, 2021.

The enrollee asked the Plan to waive the copayment for the inpatient hospital services. The enrollee said that they were on social security and cannot afford these charges. The Plan denied their request. The Plan says the enrollee has been charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay $275 per day for days 1-6 and $0 per day after day 6 for each inpatient benefit period. 

The record shows that the enrollee was in the hospital from September 7, 2021, to September 15, 2021. Therefore, the enrollee has been asked to pay $275 per day for the first 6 days of inpatient hospital services.

The total for the inpatient stay is $1650 ($275 copayment x 6 days = $1650). The inpatient hospital services fall within the Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from September 7, 2021, to September 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex device.  You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.  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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has severe foraminal stenosis at L3-L4 and mild central stenosis at three levels. The record indicates that a repeat Magnetic resonance imaging (MRI) and dual-energy x-ray absorptiometry (DEXA) scan was ordered. The results of these studies are not available. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
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 IRF admission is 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 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 the medical records show you are currently stable. You do not require physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions.  There are no acute or complex rehab nursing needs noted in the record. At the current level of function, you do 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. Medicare coverage criteria are not met.   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: Favorable

We decided that the Plan has to pre-approve Proton Beam Radiation Therapy (PBRT) with Image-guided
Radiation Therapy (IGRT).
You asked the Plan to pre-approve Proton Beam Radiation Therapy (PBRT) with Image-guided Radiation
Therapy (IGRT). You say that the requested PBRT with IGRT is medically necessary. The Plan denied your
request. The Plan says that the requested PBRT with IGRT is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
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 Proton Beam Radiation Therapy
(PBRT) with Image-guided Radiation Therapy (IGRT). Our reviewer says that the requested PBRT with IGRT
is medically necessary. Our physician reviewer found the need for proton therapy for prostate cancer is
medically necessary as the LCD criteria appear to have been met. Per the LCD, coverage is "limited to
providers who have demonstrated experience in data collection and analysis with a history of publication on the
peer-reviewed medical literature" The following applies: https://pubmed.ncbi.nlm.nih.gov/?term=hartsell+W.
Specifically for prostate cancer, the LCD (L30575) requires physician documentation of the patient "stage and
other factors" (which would include Gleason score and PSA) and documentation of the range of therapy
choices which is documented in the consultation note.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Proton Beam Radiation Therapy (PBRT) with Image-guided Radiation Therapy
(IGRT) have been met. Therefore, we decided that the Plan has to pre-approve Proton Beam Radiation Therapy
(PBRT) with Image-guided Radiation Therapy (IGRT).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 13, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services provided by an out-of-network provider on October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sit-to-stand system provided on October 2, 2021.

You asked the Plan to pay for the services provided. You say that the machine is needed to lift your husband up. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the sit-to-stand system provided on October 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home
use (D9630) and adjunctive pre-diagnostic test (D0431), or pay more for the periodontal scalings and root
planings (D4341) provided on September 14, 2021, and September 21, 2021.
You asked the Plan to pay for the drugs or medicaments and adjunctive pre-diagnostic test and to pay more for
the scalings and planings. You say that you should only owe the provider $460.00, not $800.00. The Plan
denied your request. The Plan says the drugs or medicaments and adjunctive pre-diagnostic test are not covered
benefits. The Plan also says that you did not contact the Plan prior to these dates of service to verify benefits
and provider eligibility.
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 drugs or medicaments dispensed in
the office for home use (D9630) and adjunctive pre-diagnostic test (D0431) are not among those covered under
this benefit. The contract says that you are responsible for a 70% coinsurance for periodontal scalings and root
planings that are provided in-network. Therefore, we decided that the Plan does not have to pay for the drugs or
medicaments dispensed in the office for home use (D9630) and adjunctive pre-diagnostic test (D0431), or pay
more for the periodontal scalings and root planings (D4341) provided on September 14, 2021, and September
21, 2021.
Please Note: The Plan says that your responsibility for the September 14, 2021, and September 21, 2021 dates
of service is $432.00. The Plan says that a call was placed to the provider's office on December 03, 2021 and a
representative confirmed a credit on your account of $374.00 and will be assessed and or refunded after your
January 2022 visit.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the new patient domiciliary or rest home visit (99326) provided on July 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the home visit. You say that your physician provided medically necessary services in good faith. In consideration for the services rendered, your doctor is seeking reimbursement. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the new patient domiciliary or rest home visit (99326) provided on July 9, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services, medical examination and evaluation provided on April 1, 2021, and June 3, 2021.
You asked the Plan to pay for ophthalmological services, medical examination and evaluation. You say that The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 service 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 ophthalmological services, medical examination and evaluation provided on April 1, 2021, and June 3, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the debridement services provided on
December 9, 2020, and February 22, 2021.
You asked the Plan to waive the copayment for the debridement services. You say that there is supposed to be
no copayment for trimming toenails. 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 $40
copayment for provider and professional services at an in-network specialist's office. For each date of service,
you have been asked to pay the allowed amount of the claim because this amount is less than the standard $40
copayment for the debridement services.
You have been asked to pay a $36.23 and $35.14 for the debridement services on December 9, 2020, and
February 22, 2021. The debridement services fall within the "Physician/Practitioner services, including
doctor's office visits" benefit category. The record shows the debridement services are considered a surgical
procedure.
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 debridement services provided on December 9, 2020,
and February 22, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided on October 1, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says records were not provided.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on October 1, 2020.