Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for psychotherapy services (90837) provided on January 20, 2021.
You asked the Plan to waive the copayment for psychotherapy services. You say that, during the COVID-19 pandemic, psychotherapy was to be offered with a $0 copayment. The Plan denied your request. The Plan says the correct copayment 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 $10 copayment for each Medicare-covered individual or group therapy session. The Plan has documented that the copayment waiver related to the COVID-19 pandemic had ended when psychotherapy services were provided on January 20, 2021. You have therefore been asked to pay a $10
copayment for psychotherapy services. Psychotherapy services fall within the "Outpatient Mental Health 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 psychotherapy services (90837) provided on January 20, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for alginate dressing (A6196) conforming bandage (A6446) foam dressing (A6210) tubular dressing (A6457) tape, non-waterproof (A4450) provided on March 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care supply. You say that you have recently changed ownership and updated your records. You believe this change may have inadvertently affected your network status, causing some claims to deny in error. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 alginate dressing (A6196) conforming bandage (A6446) foam dressing (A6210) tubular dressing (A6457) tape, non-waterproof (A4450) provided on March 10, 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 lab services provided on December 13, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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 testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 13, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia (CPT code 52260), for the enrollee.
You asked the Plan to pre-approve the cystourethroscopy. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not an emergency and there are in-network providers that can provide the service.
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 provider is in-network with the Plan. Furthermore, the Plan did not substantiate why this would be denied other than the Plan believing the provider is out-of-network. Therefore, we decided that the Plan has to pre-approve the cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia (CPT code 52260), for the enrollee.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cyclosporine caps and mycophenolic tablets provided on February 15, 2021 and March 16, 2021.
You asked the Plan to waive the coinsurance for the cyclosporine caps and mycophenolic tablets. You say that the supply of immunosuppressant medications should be covered by the Plan for 36 months from your kidney transplant. 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 20% coinsurance for each Medicare-covered Part B drug from an in-network provider. Covered drugs include immunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplant.
You have been asked to pay $285.64 for the cyclosporine caps and mycophenolic tablets.
The cyclosporine caps and mycophenolic tablets 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 cyclosporine caps and mycophenolic tablets provided on February 15, 2021 and March 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rocklatan ophthalmic solution.
You asked the Plan to pre-approve Rocklatan ophthalmic solution. You say that to prevent more nerve fiber
layer loss and more permanent vision loss you need the enrollee to continue using this drug. The Plan denied
your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug benefit.
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 Rocklatan ophthalmic solution.
Benefits for Rocklatan ophthalmic solution 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation
program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on March 29, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that the charges for the Medicare Part B drug injection is unexpected and the services were necessary to complete a stress test. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug injection on March 29, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $237.48 and 20% of that is $47.50. You have been asked to pay the total coinsurance amount of $47.50 for a Medicare Part B drug injection. A Medicare Part B drug injection falls 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 a Medicare Part B drug injection provided on March 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for syncope. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program.
Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve replacement prosthesis with a microprocessor knee unit, the Ottobock C-leg.

You asked the Plan to pre-approve replacement prosthesis with a microprocessor knee unit, the Ottobock C-leg. You say that the requested microprocessor knee unit, the Ottobock C-leg, is medically necessary. The Plan denied your request. The Plan says that the requested microprocessor knee unit, the Ottobock C-leg, is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve replacement prosthesis with a microprocessor knee unit, the Ottobock C-leg. Our reviewer says that the requested microprocessor knee unit, the Ottobock C-leg, is medically necessary. Our physician reviewer found the enrollee underwent a left transfemoral amputation of the left lower extremity in 1972, following a motorcycle accident. The Director of Limb Loss Rehabilitation writes that the enrollee received his current Total Knee in May, 2020, and the unit required refurbishing in November, 2020.

The enrollee's orthopedist writes that the Ottobock C-leg can improve the enrollee's walking, and provide more stability since it is lighter and more responsive. The director of limb loss rehabilitation writes that the enrollee reported interval residuum size reduction with loosening prosthetic fit, skin irritation with recurrent blisters from the liner system, and increased fall frequency, "nearly every time I go out." The enrollee has significant pathology in the contralateral right knee, which has obligated the use of a knee brace. A knee replacement has been advised and is planned in the foreseeable future.

Based on the documentation provided, there is a change in the physiological condition of the enrollee. Significant pathology has developed in the enrollee's contralateral right knee. There has been change in the condition of the enrollee's current device. It is not clear whether the change is irreparable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of replacement prosthesis with a microprocessor knee unit, the Ottobock C-leg have been met. Therefore, we decided that the Plan has to pre-approve replacement prosthesis with a microprocessor knee unit, the Ottobock C-leg.

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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says that rules for SNF care have not been met.
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. In this case, we needed medical records to evaluate if SNF care coverage have been met. Although we received a response to our request for information, the medical records were not included. In addition, our subsequent outreach attempts were unsuccessful. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
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 pre-approve the hospital services provided on December 30, 2020, through December 31, 2020.

You asked the Plan to pre-approve the hospital services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says that the claims processed correctly, and no reimbursement is due.

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. Specifically, the Plan has failed to forward sufficient information to substantiate their denial. The Plan has not submitted any evidence as to why they are unable to pay for these claims. The documentation submitted does not include any rationale for why the services were denied or claims to verify if the services were billed appropriately. Additionally, the record indicates that these services were emergent and should be paid at the in-network rate. It is the burden of the Health Plan to substantiate their denial with evidence. This denial is not substantiated, and we must find in your favor. Therefore, we decided that the Plan has to pre-approve the hospital services provided on December 30, 2020, through December 31, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam to diagnose and treat diseases of the eye and a refraction of the eye provided on March 12, 2021.
You asked the Plan to pay for an eye exam and a refraction. You say that you should not be responsible for these charges. The Plan denied your request. The Plan says you did not receive a routine eye exam; therefore, the refraction is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan says there is a $35 copayment for each eye exam to diagnose and treat diseases and conditions of the eye. The Plan also says the refraction is covered when you receive a routine eye exam. We looked at the file and the Plan's rules. The records show that you did not receive a routine eye exam. The records also show that you received an eye exam for diagnosis and treatment of the eye. The refraction is therefore not a covered benefit of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of an eye exam and refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam to diagnose and treat diseases of the eye (92014) and a refraction of the eye (92015) provided on March 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an acute inpatient hospital stay on March 25 to March 30, 2021.

You asked the Plan to waive the copayment for an acute inpatient hospital stay. You say that you feel the copayment should be waived because you are upset with the hospital's physical therapist who treated you very poorly. The Plan denied your request. The Plan says the correct copayment 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 $200 copayment for each day of days 1 to 5 each time you are admitted to an acute care hospital. 

You have been asked to pay a $800 copayment, or $200 for each day of a 4-day acute inpatient hospital stay.

The day of your discharge is not considered a part of your stay. An acute 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 an acute inpatient hospital stay on March 25 to March 30, 2021.