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

We decided that the Plan does not have to waive the copayment a CT scan of the face provided on September 24, 2021.
You asked the Plan to waive the copayment the CT scan. You say that the services should be covered as you were informed there would be no cost-sharing beforehand. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $300 copayment for Outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $129.55 copayment for a CT scan, which is less than the $300 stated in the Plan's contract.
The Plan states there is no record of you contacting them beforehand to verify the cost-sharing. CT scans fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment a CT scan of the face provided on September 24, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria.

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 you do not need intensive therapies, consisting of at least 3 hours of therapy per day 
at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical 
therapy, occupational therapy and speech therapy, your rehab needs can be safely met in an alternate and lower 
intensity setting such as in a skilled nursing facility (SNF). You are already appropriately admitted to a SNF.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the percutaneous radiofrequency ablation provided on June 3, 2021.

You asked the Plan to waive the copayment for the percutaneous radiofrequency ablation. You say that on the day of the procedure you were told there was no facility fee and full disclosure was not made. You say that the office didn't display any signage indicating the facility was anything other than a private practice and the fee should be waived. The Plan denied your request. The Plan says the copayment applied 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 $260 copayment for each Medicare- covered outpatient hospital facility visit.

You have been asked to pay a $260 copayment for the percutaneous radiofrequency ablation. The percutaneous radiofrequency ablation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show the procedure was billed by the hospital. 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 percutaneous radiofrequency ablation provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an orthosis provided on June 30, 2021.
You asked the Plan to waive the coinsurance for an orthosis. You say that the coinsurance applied was wrong. The Plan denied your request. The Plan says the proper coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for In-Network Medicare-covered prosthetic devices, supplies related to prosthetic devices, and orthotics. The total allowed cost was $22.75, with the coinsurance of 20% that means $4.55 ($22.75 total cost x 20% coinsurance) would be the enrollee's coinsurance cost.
You have been asked to pay a 20% coinsurance for an orthosis. An orthosis falls within the Prosthetic devices and related 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 orthosis provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a folding walker and a commode chair provided on June 30, 2021.  

You asked the Plan to waive the coinsurance for folding walker and a commode chair. You say that both items should be covered. The Plan denied your request. The Plan says the proper coinsurance was applied.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Durable Medical Equipment (DME) and Related Supplies. The total amount allowed for the folding walker was $114.83. The coinsurance amount was $22.97 ($114.83 x 20% coinsurance). The total amount billed for the commode chair was $126.38. The coinsurance amount is $25.28 ($126.38 x 20% coinsurance) 

You have been asked to pay a 20% coinsurance for the folding walker and a commode chair. The folding walker and a commode chair fall within the Durable Medical Equipment (DME) and Related 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 a folding walker and a commode chair provided on June 30, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits, and 9 additional home health aide (HHA) visits.
You asked the Plan to pre-approve the additional PT and HHA visits. You say that you are requesting an extension of services from the current physical therapists and occupational therapists since you still do not have the proper use of your hands to help you get up from a sitting position. You also say that you are using an HHA to help you shower. The Plan denied your request. The Plan says the services are reasonable based on your debility and limited range of motion of your wrist. The Plan also says that the requested number of visits are not supported in the plan of care provided for review.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional PT and HHA visits. Our reviewer says that the documentation does not support the requested frequency as being medically necessary or reasonable. Our physician reviewer found you have been receiving home health services following a fall, resulting a wrist fracture. Our reviewer found that you have made improvements with therapy, but still have overall weakness and are wearing a wrist brace. Our physician reviewer also found that ongoing therapy has been approved by the Plan, just not at the quantity/frequency requested. 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 additional PT and HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy (PT) visits, and 9 additional home health aide (HHA) visits
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient behavioral health services provided on August 13, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for the outpatient behavioral health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek out-of-network care.
 
 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 outpatient behavioral health services provided on August 13, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from September 3, 2021, to September 7, 2021.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not feel you should pay the provider anything for the surgery. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $375 copayment for each day, day(s) 1-5 for in-network inpatient hospital care.
You have been asked to pay a $375 copayment for each day of the inpatient hospital stay. ($375 x 4 days = $1,500). The inpatient hospital stay falls within the "Inpatient hospital care" 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 inpatient hospital stay provided from September 3, 2021, to September 7, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on August 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the radiology services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 radiology services provided on August 18, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx test (CPT code 81551) provided to the enrollee on September 8, 2021.
You asked the Plan to pay for the testing. You say that the service was medically necessary. The Plan denied your request. The Plan says there were no documented persistent or elevated risk factors such as an increasing prostate-specific antigen (PSA) or digital rectal exam (DRE) findings at that time and no consideration for a repeat biopsy as required by LCD 36327. The Plan states the test does not meet Medicare guidelines and is denied as not 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 pay for the testing. Our physician reviewer found the review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx test (CPT code 81551) provided to the enrollee on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the requested 
power wheelchair with multiple power options exceeds your medical need. You do have a qualifying group 3 
neurologic diagnosis, but the documentation does not reveal high risk for development of a pressure ulcer, or 
inability to perform a functional weight shift, or utilization of intermittent catheterization for bladder 
management. There is no need for a power seating system to managed increased tone or spasticity. You do not 
require non-proportional input devices (e.g., sip and puff, head array, etc.). You do not require a separate 
display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech 
device or computer through the chair's drive control), or an attendant control. The documentation does not 
support that it is medically necessary to control the requested power options through the joystick (drive 
interface). Your strength and functional ability with independence in dressing and toileting should be sufficient 
to control any power options through their own switches. The documentation does not reveal that tilt and 
recline are medically necessary or E2377 Expandable Controller, E2313 Expandable Controller Harness and 
E2311 Electro Connect Btw 2 Sys Electro Connect Btw 2 Sys are medically necessary. Therefore, the request 
for Group 3 power wheelchair with multiple power options is not 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 the wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 power wheelchair and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Ferumoxytol 1mg injection (Q0138)
provided on August 17, 2021, and August 26, 2021.

You asked the Plan to waive the coinsurance for the Ferumoxytol injection. You say that the injection should
be covered at a higher rate as you received the same services on August 26th, 2021, and it was cheaper. The
Plan denied your request. The Plan says the coinsurance applied correctly based on the injection provided and
they cannot change the way the provider has billed for the 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 20%
coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for a Ferumoxytol injection (the allowed amount is $563.79 x
20% = $112.76). Ferumoxytol injections fall within the Medicare Part B prescription drugs 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 the Ferumoxytol 1mg injection (Q0138) provided on
August 17, 2021, and August 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is improving but still requires ongoing acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visits, and the pessary 
provided on April 2, 2021, and April 30, 2021.

You asked the Plan to waive the cost share for the specialist office visits and the pessary. You say that you 
were told there would be no charge for the visit on April 30, 2021. You say you already paid for the April 2, 
2021, visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 
amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each specialist office visit for Medicare-covered services 20% of the cost for each Medicare- 
covered item.
 
You have been asked to pay a $40 copayment for each of the specialist office visits. You have been asked to 
pay $10.08 which is 20% of the allowed amount for the pessary. The allowed amount is $50.39. ($50.39 x 20% 
= $10.08). The specialist office visits fall within the "Physician/Practitioner services, including doctor's office 
visits" benefit category. The pessary falls within the "Prosthetic devices and related 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 cost share for the specialist office visits, and the pessary provided on April 
2, 2021, and April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuropathy treatment provided on October 7, 2021.
You asked the Plan to pay for the neuropathy treatment. You say that this treatment was medically necessary
for your condition. The Plan denied your request. The Plan says payment cannot be made for services excluded
from coverage.
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 pay for the neuropathy treatment. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation indicates that the requested procedures were denied as noncovered.
Based on the member submitted clinical information that revealed symptoms improved after
treatments. However, Medicare does not allow coverage for these treatments as they are statutorily excluded.
The review has determined that the items/services at issue in this case are 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 neuropathy treatment have not been met. Therefore, we decided that the Plan does not have to pay for the neuropathy treatment provided on October 7, 2021