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

We decided that the Plan does not have to pre-approve Vyzulta Ophthalmic Solution.  You asked the Plan to pre-approve Vyzulta. You say that alternatives have been tried, and were unsuccessful. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vyzulta Ophthalmic Solution,  Benefits for Vyzulta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory testing and physician services
provided on June 25, 2019.
You asked the Plan to waive the coinsurance for lab test and specialist services. You say that you were not
aware that this provider was out-of-network. The Plan denied your request. The Plan says the coinsurance
amount 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 50%
coinsurance for out-of-network lab test and specialist services. The allowed amount of this claim is $365.80,
resulting in a coinsurance obligation of $182.90.
You have been asked to pay 50% coinsurance for lab test and specialist services. Lab test and specialist
services fall within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" and
"Physician/Practitioner Services, Including Doctor's Office Visits" benefit categories. 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 laboratory testing and physician services provided on June
25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to an inpatient mental health facility for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says active treatment is no longer being provided, with a need for acute inpatient 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 the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 13, 2020 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, being non-compliant with treatment while not having auditory or visual hallucinations. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to an inpatient mental health facility for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on February 26, 2019.
You asked the Plan to pay for the ophthalmological services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services.
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 service 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 ophthalmological services provided on February 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the office visit provided on June 11,
2019.
You asked the Plan to reduce the coinsurance for the office visit. You say that you were not aware the provider
was out-of-network. You say you were told you would only need to pay your copayment. 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 50% of
the Medicare-allowed amount for out-of-network primary care provider visits or out-of-network specialist
visits for Medicare-covered services.
You have been asked to pay $51.68 which is 50% of the allowed amount for the office visit. The allowed
amount is $103.36. ($103.36 x 50% = $51.68). The office visit falls within the "Physician/Practitioner services,
including doctor's office visits" benefit category. The record shows the provider is out-of-network.
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 reduce the coinsurance for the office visit provided on June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant control for a wheelchair for the enrollee.
You asked the Plan to pre-approve the attendant control. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 attendant control. Our reviewer says that the requested attendant control is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee is unable to operate a manual or power wheelchair. The documentation does not reveal that the enrollee has a caregiver who is unable to operate a manual wheelchair but able to operate a power wheelchair. 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 attendant control have not been met. Therefore, we decided that the Plan does not have to pre-approve attendant control for a wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the occlusal guard (D9942) provided on August
22, 2019.
You asked the Plan to reimburse you for the dental item. You say that you have been diagnosed with TMD.
You say that since acquiring this appliance your symptoms have vastly improved. You also say that this is a
medical condition and should be reimbursed under your health care plan. The Plan denied your request. The
Plan says the dental item you received is not eligible for coverage.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to reimburse you 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 reimburse you for the
occlusal guard (D9942) provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services and physician services
provided on February 13, 2019.
You asked the Plan to waive the coinsurance for the laboratory services and physician services. You say that
you were informed everything was covered fully. You say that you were not aware the provider was out-of-network.
The Plan denied your request. The Plan says the coinsurance 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 50% of
the Medicare-allowed amount for out-of-network specialist services and 50% of the Medicare-allowed amount
for laboratory services in all out-of-network settings.
You have been asked to pay $193.62, which is 50% of the allowed amount for the laboratory services and
physician services. The allowed amount is $387.24 (50% x $387.24 = $193.62). Laboratory services fall within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Physician services fall
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 coinsurance for laboratory services and physician services provided on February 13,
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diapers (T4521) and disposable underpads (A4554).
You asked the Plan to pre-approve diapers and disposable underpads. You say that the enrollee needs these items due to her incontinence and Alzheimer's. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve diapers (T4521) and disposable underpads (A4554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the applied copayment for the chiropractic manipulative treatment (98941) provided from August 12, 2019 to August 29, 2019.
You asked the Plan to adjust the applied copayment. You say that the copayment has been applied incorrectly. The Plan denied your request. The Plan says that they have processed and paid the claims correctly with a $10 copayment applied for each chiropractic office visit.
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 $10 copayment for each Medicare-covered chiropractic office visit with a participating provider. You have been asked to pay a $60 copayment ($10 X 6 office visits) for Medicare-covered chiropractic services. 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 adjust the applied copayment for the chiropractic manipulative treatment (98941) provided August 12, 2019 to August 29, 2019.
Your complaint about the additional charges assessed by the chiropractic office 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.
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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory care including BiPAP and oxygen supplementation, nebulizer treatments, surveillance laboratory studies, hemodialysis, intravenous antibiotics, intravenous diuretics, wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 23, 2019, to May 24, 2019.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says inpatient care 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 the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then 74-year-old female with a history of HTN, DM, CVA with residual left-sided weakness and ESRD on HD. She presented to the ED on May 23, 2019, for the evaluation of chest pain. She was getting a fistulogram prior to the onset of pain. The evaluation revealed stable vital signs and the physical exam was unremarkable. Lab studies revealed normal cardiac biomarkers and the EKG was without any acute ischemic changes. She was treated with IV H2 blocker and admitted to telemetry. Her condition stabilized and improved and she was discharged home on May 24, 2019. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED 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 the acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 23, 2019, to May 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 21, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to pay because you were misdiagnosed. The Plan denied your request. The Plan says that the copayment was 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 $150 copayment for ambulance trips. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the ambulance trips 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 transport provided on August 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for a skilled nursing facility stay provided on August 21, 2019 to September 28, 2019.
You asked the Plan waive the copayment for a skilled nursing facility. You say that your family has a lot of financial hardship. You say that you would like the Plan to pay your portion of your stay. The Plan denied your request. The Plan says the correct copayment has been 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 $0 copayment per day for days 1-31. There is a $25 copayment per day for days 32-100 for skilled nursing facility. You have been asked to pay a $0 copayment per day for days 1-31. There is a $25 copayment per day for days 32-39 for a skilled nursing facility. The total amount you are being asked to pay is $175 ($25 x 7 days = $175). A skilled nursing facility falls within the skilled nursing facility 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 waive the copayment for a skilled nursing facility stay provided on August 21, 2019 to September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by anout-of-network provider on April 29, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there are network providers available to provide these services.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 has network providers available who can provide 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 forthe medical services provided to the enrollee by an out-of-network provider on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 13, 2019 to November 1, 2019.
You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for test strips, lancets, control solution, and batteries provided from August 13, 2019 to November 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on September 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements. We looked at the file and Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the glycosylated hemoglobin testing provided on September 3, 2019.
You asked the Plan to pay for the glycosylated hemoglobin testing. 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 a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the glycosylated hemoglobin testing provided on September 3, 2019.