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

We decided that the Plan does not have to waive the $250 copayment charged for ambulance transport provided on March 17, 2021.

You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment is a contractual obligation.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way ambulance transport. 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 $250 copayment charged for ambulance transport provided on March 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on June 16, 2021.
You asked the Plan to pay for the eye exam. You say that you have poor vision in one eye and was referred to this visual independence group. The Plan denied your request. The Plan says you must use the Plan's vision provider.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you use a provider in the Plan's vision care network.
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. We looked at the file and the Plan's rules. The file shows that the eye exam was not provided by a provider in the Plan's vision care network. The Plan did not pre-approve the eye exam. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam provided on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no documented trial of conservative therapy demonstrating failed response to treatment with a basic pump.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided do not indicate that the enrollee has lymphedema extending onto the chest, trunk and/or abdomen. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from
November 22, 2021, forward.
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that you feel a
continued inpatient psychiatric stay should be covered for the enrollee. The Plan denied your request. The Plan
says the enrollee does not have medical issues that require treatment at an inpatient psychiatric level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 continued inpatient psychiatric admission. Our reviewer says that a continued inpatient psychiatric admission from November 22, 2021, forward is not medically necessary. Our physician reviewer found this enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment from November 22, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors while being cooperative and compliant. 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 continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from November 22, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient periodic preventive medicine examination (99397) provided on May 27, 2021.
You asked the Plan to pay for the preventive medicine examination. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this benefit has been exhausted for the calendar year.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. The Plan has demonstrated that they have already paid for one AWV and this request exceeds the benefit limit. Therefore, we decided that the Plan does not have to pay for the established patient periodic preventive medicine examination (99397) provided on May 27, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a Fitbit fitness tracker purchased on July 12, 2021.

You asked the Plan to pay for the Fitbit. You say that this should be covered as it was recommended by your physician to monitor your heart rate. The Plan denied your request. The Plan says this item is not covered by Medicare or by your Plan's supplemental health and wellness benefit.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $150 per calendar year toward the cost of membership in a qualified health club or fitness facility, certain wellness programs, acupuncture and/or covered nutritional counseling sessions with a licensed nutritional counselor or registered dietician. 

The Plan's rules for coverage of gym benefits have not been met because exercise equipment and/or fitness trackers are not listed as a covered benefit under Medicare or under the Plan's supplemental benefits. Therefore, we decided that the Plan does not have to pay for a Fitbit fitness tracker purchased on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided by a provider who has opted out of the Medicare program.

You asked the Plan to pay for the dermatology services provided by an opted out of Medicare provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dermatologist who provided these services to you has opted out of the Medicare program.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dermatology services provided by a provider who has opted out of the Medicare program.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for a pulmonary function test provided on April 22, 2021.
You asked the Plan to waive the copayment for the pulmonary function test. You say that you did not have a pulmonary function test on this date of service. The Plan denied your request. The Plan says that the copayment applied correctly based on the services provided.
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 Plan failed to forward us the medical records that would support the services being billed, we are unable to determine whether the copayment being assessed is correct. Therefore, we decided that the Plan has to waive the copayment for a pulmonary function test provided on April 22, 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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 28, 2021, to July 9, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you strongly believe the services provided to this enrollee were medically necessary and required an inpatient setting. The Plan denied your request. The Plan says that the inpatient stay was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 28, 2021, to July 9, 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 copayment for a pulmonary function test provided on June 1, 2021.
You asked the Plan to waive the copayment for the pulmonary function test. You say that you did not have a pulmonary function test on this date of service. The Plan denied your request. The Plan says that the copayment applied correctly based on the services provided.
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 Plan failed to forward us the medical records that would support the services being billed, we are unable to determine whether the copayment being assessed is correct. Therefore, we decided that the Plan has to waive the copayment for a pulmonary function test provided on June 1, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99222) and subsequent hospital care (99232) provided from March 22, 2021, to March 24, 2021.
You asked the Plan to pay for the initial hospital care and subsequent hospital care. You say that the enrollee did not sign onto hospice until March 25, 2021, which was after this date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on March 16, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) and subsequent hospital care (99232) provided from March 22, 2021, to March 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips.
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 available from the preferred providers.
The Plan must follow Medicare rules. The rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies. We looked at the file and Medicare rules. The file shows that the requested diabetic test strips are from a provider that is not a preferred provider with the Plan. Diabetic test strips are available from the preferred providers. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ultrasound of the head and neck, an aspiration procedure, and an emergency department visit provided from March 26, 2021, to May 27, 2021.

You asked the Plan to waive the copayments for the ultrasound, aspiration procedure, and emergency department visit. You say that you were advised that the Plan is covering all coronavirus expenses. 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 $160 copayment for each radiological diagnostic service, including ultrasounds.

Your contract with the Plan also clearly says that enrollees must pay a $325 copayment for each surgery or other service provided at an outpatient hospital.

Your contract with the Plan also clearly says that enrollees must pay a $90 copayment for each emergency room visit.

You have been asked to pay $130.15, which is less than the $160 copayment for the ultrasound. Ultrasounds fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay a $325 copayment for the aspiration procedure. Aspiration procedures fall within the Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. You have also been asked to pay a $90 copayment for the emergency department visit. Emergency department visits fall within the Emergency Care benefit category. The total for these services is $545.15. Please note that the Plan's coronavirus temporary provisions say that there are no cost share waivers in effect for coronavirus treatment. 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 an ultrasound of the head and neck, an aspiration procedure, and an emergency department visit provided from March 26, 2021, to May 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 6, 2021.

You asked the Plan to pay for the services provided. You say that supporting documentation was provided. The Plan denied your request. The Plan says they cannot determine whether the services were medically necessary.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that the billed services are not supported in the medical record. Specifically, there is no consultation note to indicate why the testing was ordered. There is no indication the services were urgent or emergent. The file shows that the Plan made multiple attempts to obtain additional information, but none was received. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure codes 27486, 27665) provided to the enrollee on April 30, 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 the operative report did not include documentation of the denied codes.

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 the denied codes is: 

CPT 27486: 

Revision of total knee arthroplasty, with or without allograft; 1 component 

CPT 27665: 

Repair, extensor tendon, leg; secondary, with or without graft, each tendon

We asked our coder 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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the operative report does not include enough detail to confirm a total knee revision (CPT 27486) has been performed. The operative report describes removal of polyethylene; however, no documentation was included to describe a revision, and therefore cannot be confirmed as performed. In terms of CPT 27665, the operative report does not include documentation of a tendon repair. The operative report describes evaluation of the polyethylene, and therefore, a repair cannot be confirmed as performed.

We looked at this coder's review, the file, and Medicare rules. 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 surgical services (procedure codes 27486, 27665) provided to the enrollee on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit you had on January 28, 2021.
You asked the Plan to waive the copayment for the podiatry visit. You say that this was related to post-COVID symptoms, so the copayment should be waived. The Plan denied your request. The Plan says there was no copayment waiver in effect at the time of these services.
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 $45 copayment for podiatry services. You have been asked to pay a $45 copayment for the podiatry visit. Please note that the Plan's website explicitly states that the Plan is not waiving cost sharing for COVID-19 treatment. The website states that you
will be responsible for cost sharing according to your benefit plan for COVID-19 treatment. 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 podiatry visit you had on January 28, 2021.