Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Freestyle Libre Sensor.  You asked the Plan to pre-approve the Freestyle Libre Sensor. You say that you need this item. The Plan denied your request. The Plan says you are not on insulin three times or more a day.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess 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. Based on this information, we decided that Medicare rules for coverage of the Freestyle Libre Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre Sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99204) rendered on March 4, 2021.  You asked the Plan to waive the copayment for an office visit with a specialist. You say that you have never paid any copayment and your policy does not ask for any copayments. The Plan denied your request. The Plan says you were charged the correct copayment 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 $10 copayment for in-network specialty care physician services, including office visits.   You have been asked to pay a $10 copayment for an office visit with a specialist. An office visit with a specialist 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 copayment for an office visit with a specialist (99204) rendered on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite (D2392), a comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided by an out-of-network provider on December 3, 2020, to December 16, 2020.  You asked the Plan to pay for a resin-based composite, a comprehensive oral evaluation, and prophylaxis. You say that you were unaware you had not signed up for dental. The Plan denied your request. The Plan says services must be provided by an in-network provider.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for a resin-based composite (D2392), a comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided by an out-of-network provider on December 3, 2020, to December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sensors for a Freestyle Libre continuous glucose monitor (CGM).  You asked the Plan to pre-approve these services. You say that the device is helpful for your medical needs. The Plan denied your request. The Plan says the criteria for coverage are not met.  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 you do not treat with insulin three or more times per day. 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 sensors for a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression sleeve.  You asked the Plan to pre-approve the compression sleeve. You say that the item is medically necessary. The Plan denied your request. The Plan says they are not re-usable and able to be rented to another member.  The Plan must follow Medicare rules. The rules say that compression sleeves are noncovered because they do are not re-usable.  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression sleeve.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation provided on June 2, 2021.  You asked the Plan to waive the copayment for the ambulance trip. You say that you were unable to walk after being in the intensive care unit (ICU) for 29 days and needed the transport. The Plan denied your request. The Plan says you have 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). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way ambulance trip.   You have been asked to pay $237.25, which is less than the $250 copayment for the ambulance trip. Ambulance transportation 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 the ambulance transportation provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99204) provided on  May 27, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for a specialist visit.   You have been asked to pay a $40 copayment for the telehealth specialist visit provided. A notification issued to you by the Plan on April 27, 2020 stated that cost sharing would apply if a specialist visit could be performed by video or by phone. 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 (99204) provided on May 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2781, V2745, V2025, V2781, V2744) purchased on July 1, 2021, from an out-of-network provider.  You asked the Plan to pay for the eyeglasses. You say that you needed new glasses and did not realize this provider was out-of-network or that out-of-network vision care was not covered. The Plan denied your request. The Plan says routine vision services must be provided through the Plan's specified routine vision vendor in order to be eligible for payment. These services were received out-of-network.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $200 for routine eyewear when purchased through the Plan's specified routine vision vendor network.  We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's specified network. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2781, V2745, V2025, V2781, V2744) purchased on July 1, 2021, from an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on June 24, 2019.  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 this claim was not filed within the required Medicare time limit.  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 these services was not filed until August 13, 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 physician services provided to the enrollee on June 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) and the laboratory services (36415, 81002, 85025) rendered by the OON provider on August 19, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.    The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99204) and the laboratory services (36415, 81002, 85025) rendered by the OON provider on August 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for inpatient hospital care at diagnosis related group (DRG) 683 provided from February 21, 2021, to February 23, 2021.  You asked the Plan to pay for inpatient hospital care. You say that diagnosis code N17.9 is supported by the medical record. The Plan denied your request. The Plan says that the denial of payment at the requested DRG is correct, because N17.9 is not supported as the principal diagnosis and the Plan has approved DRG 690 instead.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with N17.9 - acute kidney failure, unspecified. 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 inpatient hospital care. Our reviewer says that this inpatient stay meets criteria for payment at the requested diagnosis related group (DRG). Our physician reviewer found documentation supports deterioration of kidney function (increase in creatinine levels) with or without reduced urine output, and intravenous (IV) hydration. Renal replacement therapy is not required to be diagnosed with acute renal failure, and can be resolved with vigorous treatment, as documentation supports.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital care at diagnosis related group (DRG) 683 provided from February 21, 2021, to February 23, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the lower extremity for the enrollee.  You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says CT scan of the knee for pre-operation planning is still under investigation.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the pre-operative CT scan for total knee arthroplasty to be an effective and/or safe treatment for the noted pathology. There were no exams provided for review to indicate any significant outliers to this. Ultimate outcome differences with regards to pain reduction and improved functionality have not been shown to be significantly improved with such a diagnostic. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for CT scan of the knee for pre-operative planning is not medically reasonable or 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 the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan of the lower extremity for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the eyeglasses (V2020, V2200) purchased post-cataract surgery on May 24, 2021.  You asked the Plan to waive the deductible for the eyeglasses. You say that you chose this provider because you had been happy with their services in the past and they are one of the cheaper options for eyewear. You did not realize this provider was out-of-network and were hoping to save money for yourself and the Plan. The Plan denied your request. The Plan says the eyeglasses are covered; however, the provider in this case is out-of-network, and therefore your $1,000 out-of-network deductible applies to these services.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible which applies to out-of-network Medicare-covered vision care.   The eyeglasses in this case are considered Medicare-covered vision care, as they are eyeglasses provided post-cataract surgery. The provider in this case is out-of-network with both the Plan's medical network and the Plan's routine vision vendor network. Therefore, the out-of-network deductible applies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible which applies to out-of-network Medicare-covered vision care. This cost sharing is a contractual obligation that had not been met at the time the eyeglasses was received on May 24, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the eyeglasses (V2020, V2200) purchased post-cataract surgery on May 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-share for the myocardial perfusion imaging, tomographic (SPECT) scan (78452) and echocardiography (93306) provided on July 22, 2021.  You asked the Plan to waive the cost-share for the SPECT and echocardiography. You say that these services were pre-approved, and you feel the deductible should be waived. The Plan denied your request. The Plan says that this claim was processed correctly, and your cost-share was assessed in accordance with your contract. You had not met your deductible at the time of service, so your deductible amount and your copayments for these services 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 $750 deductible for basic and advanced diagnostic imaging services. This is the amount you have to pay out-of-pocket before the Plan will pay their share for your covered medical expenses. After your deductible is met, you are responsible for a $200 copayment for each advanced diagnostic imaging service and a $10 copayment for each basic diagnostic imaging service.  The tests you asked the Plan to waive the cost-share for fall within the advanced diagnostic imaging services benefit category and the basic diagnostic imaging services category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies to this diagnostic imaging services. This cost sharing is a contractual obligation that had not been met at the time these services were provided on July 22, 2021.  You have been asked to pay $950 for the SPECT. Documentation shows that at the time of services, you had previously paid $0 toward your deductible. The provider billed the Plan $7,184 for the SPECT scan. The Plan's allowed cost for this service is $1,149.81. You are responsible for your $750 deductible before the Plan will pay their share for covered services. You are also responsible for the $200 copayment for the advanced imaging service, as the allowed cost of this service exceeds your deductible amount. You are responsible for your deductible and copayment for this service, and the remaining cost is covered by the Plan.  You have also been asked to pay a $10 copayment for the echocardiography. You met your deductible in the cost of the previous service, and therefore only the $10 copayment for the basic diagnostic imaging service applies to the echocardiography. This means that you have been asked to pay the correct amount for these services 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 cost-share for the myocardial perfusion imaging, tomographic (SPECT) scan (78452) and echocardiography (93306) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee does not receive at least 3 insulin injections per day.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.    We looked at the file and Medicare rules. The documentation does not indicate that the enrollee uses insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).  You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that your doctor feels that this item is best so you would like to appeal the denial. The Plan denied your request. The Plan says this item is not a covered benefit under Medicare as it is considered not reasonable and necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.           We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218).