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

We decided that the Plan does not have to waive the copayment for the office visit with a gastroenterologist
you had on June 14, 2021.

You asked the Plan to waive the copayment for the gastroenterology visit. You say that you already paid the
copayment before being seen. The Plan denied your request. The Plan says you were charged this copayment
correctly. The Plan says that they contacted the provider, and the provider has no record of your paying your
copayment. In addition, there is no receipt showing that you made this payment.

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 visits with a specialist.

You have been asked to pay a $20 copayment for the gastroenterology visit. 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 office visit with a gastroenterologist you had on June 14, 2021.

Your complaint about you paying the copayment in cash to the 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on May 13, 2020.
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 due to the enrollee's hospice election at the time of service, this claim must be sent to
Original Medicare first for review.
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 medical services provided to the enrollee on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1390) and a backpack
(E1399) provided on May 19, 2021.

You asked the Plan to pay for a portable oxygen concentrator and a backpack. You say that the requested items
are a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been
met.

The Plan must follow Medicare rules. The rules say that purchased oxygen equipment is statutorily noncovered. The rules also say that for equipment to be covered, it must primarily serve a medical purpose.

The portable oxygen concentrator at issue in this appeal was purchased, not rented. The backpack at issue in
this appeal does not serve a purpose that is primarily medical in nature. The backpack 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 a portable oxygen concentrator (E1390) and a backpack (E1399) provided on
May 19, 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 IRF care is not medically reasonable and necessary. The Plan denied your request. The Plan says rules for IRF care have not been met
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the patient was admitted for two stage thoracic and lumbar surgery, complicated
by pneumothorax requiring a chest tube, atrial fibrillation with rapid ventricular response and wound infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on March 31,
2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the time limit for filing has expired.
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 was not filed until June 16, 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 physician services provided to the enrollee on March 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan (71250) provided on
August 10, 2021.
You asked the Plan to pay for CT scan 71250. You say that you are appealing with records to support this level
of service. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because code 71250 has a procedure-to-procedure (PTP) edit with code 71275 and is not separately payable
without an appropriate modifier.
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 CT
scan 71250 is a column II code to column I code 71275. This claim has not been billed with an appropriate
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan (71250)
provided on August 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee has not had a trial and failure or Retacrit.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee has anemia of chronic renal disease. The requested medication is a new start. The provided records
do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does
not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's
preferred step one alternative. The elements of the coverage criteria are not satisfied.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Procrit for the enrollee.
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 this is medically necessary. The Plan denied your
request. The Plan says the enrollee could benefit adequately and safely at a lower level of care, such as skilled
nursing home.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for surgical repair of an ankle fracture after a fall. Medical problems are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on May 14, 2021.

You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you were told that you
would not owe anything for the colonoscopy. 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 any surgical procedures provided during a colonoscopy screening and a $150 copayment for
outpatient surgery, including services provided at ambulatory surgical centers.

You received a colonoscopy on May 14, 2021. The diagnostic codes provided on the claim show that the
colonoscopy was ordered for diagnostic purposes. Therefore, you are responsible to pay the $150 copayment.

You have been asked to pay a $150 copayment for a diagnostic colonoscopy. A diagnostic colonoscopy falls
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers benefit category. This means that you have been asked to pay the correct amount based on your
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy
provided on May 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an MRI provided on August 4, 2021.
You asked the Plan to waive the coinsurance for an MRI. You say that you did not receive an MRI on this date
of service. 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 20%
coinsurance up to $75 for MRI's.
The medical records show that you received an MRI on August 4, 2021. Therefore, you are responsible to pay
$75.
You have been asked to pay $75 for an MRI. An MRI 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 coinsurance for
an MRI provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services received on January 11, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says services must be rendered by a plan-contracted dentist.
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 dental services received on January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement K3 lower extremity prosthesis and socket.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a replacement prosthesis and socket are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no documentation supporting that you meet the criteria for coverage for the requested services. The records show that you need a power wheelchair for mobility, which is not consistent with a K3 level ambulator. The K3 prosthesis and associated socket are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement K3 lower extremity prosthesis and socket
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of eye shunt for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there needs to be clinical notes showing mild to moderate stage glaucoma.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has severe glaucoma. The elements of the coverage criteria are not satisfied. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of eye shunt for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound you had on July 12, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that the Plan hardly paid anything
towards this service, and you think the Evidence of Coverage is not clear. 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 $135
copayment for radiological diagnostic services.

You have been asked to pay a $135 copayment for the ultrasound. The ultrasound falls within the 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 ultrasound you
had on July 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of eye shunt for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there needs to be clinical notes showing mild to moderate stage glaucoma.
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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the record indicates that the enrollee has severe glaucoma. The elements of the coverage criteria are not satisfied. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of eye shunt for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in an alternate level of care.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an
outpatient hospital facility on May 12, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you have always had
colonoscopies done in an ambulatory surgery center and never had to pay a copayment. This time, you had this
service in a hospital and you were charged a copayment. You stated that the copayment should be waived
because you were unaware of the copayment. 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 $150
copayment for visits to an outpatient hospital facility (including surgery).
You have been asked to pay a $150 copayment for the diagnostic colonoscopy. You had this service in an
outpatient hospital facility, so the 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 copayment for
the diagnostic colonoscopy you had at an outpatient hospital facility on May 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on September 2, 2020.
You asked the Plan to pay for the physical therapy services. You say that medical records required to reprocess
the denied claim are attached. 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 the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services
provided by a physical therapy assistant on September 2, 2020.