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

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with polyp removal you had at an ambulatory surgery center on June 30, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you are on a fixed income and you were not aware this service would not be covered. 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 $500 copayment for outpatient surgery and services at an ambulatory surgery center. You have been asked to pay a $500 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the outpatient surgery and services at an ambulatory surgery center 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 diagnostic colonoscopy with polyp removal you had at an ambulatory surgery center on June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), therapeutic, prophylactic, or diagnostic injection (96372), triamcinolone acetonide injection (J3301), and the non-invasive ear or pulse oximetry for oxygen saturation (94760) rendered by the out-of-network (OON) provider on February 2, 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 (99214), therapeutic, prophylactic, or diagnostic injection (96372), triamcinolone acetonide injection (J3301), and the non-invasive ear or pulse oximetry for oxygen saturation (94760) rendered by the out-of-network (OON) provider on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) for tooth #15.
You asked the Plan to pre-approve the crown. You say that this service is necessary. The Plan denied your request. The Plan says crowns are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain fused to predominantly base metal crown (D2751) for tooth #15.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit (99285) provided on June 9, 2021, to June 12, 2021, by a non-participating facility
You asked the Plan to waive the copayment for an emergency department visit. You say that that due to the incompetence of the service provided, you feel that the Plan should waive your out-of-pocket expenses for your hospital care. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $90 copayment for emergency care.
You have been asked to pay a $90 copayment for an emergency department visit. The EOC confirms that $90 is the required copayment for this service. The record shows that the provider billed the services as outpatient, and there was no formal inpatient order. 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 emergency department visit (99285) provided on June 9, 2021, to June 12, 2021, by a non-participating facility
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services you had on June 3, 2021.
You asked the Plan to waive the copayment for the lab services. You say that the plan should cover your lab work because it is part of getting a wellness exam done. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan said that you are not being charged for the lipid panel you received.
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 lab services. You have been asked to pay a $10 copayment for the lab services. Your Evidence of Coverage explicitly states that separate cost sharing applies for lab services ordered or performed as part of an annual wellness exam. 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 lab services you had on June 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the enrollee plateaued in therapy and is no longer making much progress. The Plan states the enrollee has no assistance at home and will need twenty-four (24) care. The Plan denied your request. The Plan says the enrollee does not meet Medicare guidelines because the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan states all the services the enrollee needs are offered at the IRF. The Plan states transfer to a SNF for inpatient skilled rehabilitation services is not medically necessary.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.
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 and does not require frequent self-adjustment of insulin dosage based on the
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 26, 2021, to  
May 28, 2021.  

You asked the Plan to pay for acute inpatient hospital care. You say that the services provided were medically 
reasonable and necessary. The Plan denied your request. The Plan says that this request is not medically 
necessary because the records do not show that the enrollee had recurrent seizures or persistent symptoms. The 
Plan also says that the enrollee's symptoms improved during the observation period.  
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 enrollee presented to the hospital via emergency medical services on May 26,2021 with a 
seizure. The enrollee has a history of a seizure disorder. Our reviewer found that the enrollee received 
intravenous (IV) Ativan and Magnesium Sulfate and was started on IV Keppra. Her oral seizure medication 
dose was increased. The enrollee's mental status returned to normal, and she was discharged home when 
considered medically stable on May 28, 2021. Our physician reviewer also found that the record shows that at 
the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 May 26, 2021, to May 28, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on July 3, 2021.
You asked the Plan to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.
We find that CPT code 99053 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that this payment for this code is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility coded 99053 provided on July 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had to an urgent care facility on January 18, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were told this was a follow-up visit and there was no copayment. You said that had you known this would not be covered in full, you would have gone to your primary care office instead. 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 $50 copayment per visit for urgent care visits. You have been asked to pay a $50 copayment per visit for the urgent care visit. This copayment is charged per
visit, regardless of the reason for the visit. There is no provision in your contract for a waiver of this copayment for follow-up care. 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 visit you had to an urgent care facility on January 18, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided between 10:00PM and 8:00AM (99053) provided on July 2, 2021.
You asked the Plan to pay for medical services. You say that the Plan should process this claim at the reasonable and customary allowance. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99053 is always bundled for payment and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that code 99053 is always bundled for payment and, if covered, the payment for this code is subsumed by the payment for the services to which it is incident. We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of medical services have not been met. Therefore, we decided that the Plan does not have to pay for services provided between 10:00PM and 8:00AM (99053) provided on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a white glass and gold crown (D2752) for tooth #14.
You asked the Plan to pre-approve the crown. You say that your previous crown is broken and requires replacement. The Plan denied your request. The Plan says you previously had a crown provided for this tooth in February 2017. This service can only be covered once per tooth every 60 months. It has not been 60 months since your previous crown; therefore, this service is denied.
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. The Plan can cover one porcelain or stainless-steel crown per tooth every 60 months. Though the Plan offers a dental benefit in excess of Medicare coverage, the crown is requested in a frequency that is not covered under this benefit. Documentation shows that you previously had a crown for this tooth in February 2017, which was covered by the Plan at that time. It has not been 60 months since you last had a
crown on the requested tooth. Therefore, we decided that the Plan does not have to pre-approve a white glass and gold crown (D2752) for tooth #14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a high frequency chest wall oscillation system to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are equally qualified in-network suppliers who can provide the equipment being requested.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit services provided on January 8, 2021, to January 29, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the hospital outpatient clinic visit services. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit services provided on January 8, 2021, to January 29, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom car seat.
You asked the Plan to pre-approve a custom car seat. You say that you are unable to travel without this item. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a custom car seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary due to significant 
deformity. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device.
You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device.