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

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 7, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you couldn't be transferred another way. You say that you shouldn't have to pay copayments out-of-pocket. 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 $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay $226.30, which is less than the standard $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" 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 December 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve consultation for a restorative obesity surgery, endoluminal (ROSE) procedure to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the OON surgical consultation for the ROSE procedure. You say that it is felt that the ROSE procedure would be the best option and she has been approved by cardiology for this type of procedure. As such, she must consult with the OON surgeon as no network surgeons are able to perform this procedure.The Plan denied your request. The Plan says there are network providers able to provide the necessary care for this enrollee.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 provider at issue in this case is not a network provider with the Plan. 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 OON surgical consultation for the ROSE procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary; therefore, consultation with the requested OON surgeon is not required. Our physician reviewer found the enrollee is a female with morbid obesity and a history of Crohn's disease. The requested procedure is not a standard treatment for morbid obesity. It is considered investigational as a primary treatment for morbid obesity. Thereare some bariatric procedures that are not contraindicated for patients with Crohn's disease which include sleeve gastrectomy and the laparoscopic adjustable gastric band procedure. 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 OON surgical consultation for the ROSE procedure have not been met. 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 the OON surgical consultation for the ROSE procedure.Therefore, we decided that the Plan does not have to pre-approve consultation for a restorative obesity surgery, endoluminal (ROSE) procedure to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forunspecified removable prosthodontic procedure, by report (D5899) and complete denture -maxillary (D5110) provided on March 19, 2020.You asked the Plan to pay forthe dental services. You say that you were saving the Plan money by using previous denture teeth to add to your new dentures.The Plan denied your request. The Plan says the services are not a covered benefit under the plan.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. The services are not listed in your EOC as a covered benefit; therefore, the services are not covered.Therefore, we decided that the Plan does not have to pay forunspecified removable prosthodontic procedure, by report (D5899) and complete denture -maxillary (D5110) provided on March 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
You asked the Plan to pre-approve the sensors and transmitter. The Plan denied your request. The Plan says that this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on November 7, 2019. You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records to support the lab codes billed. The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on November 7, 2019.
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 you are requesting reconsideration as the enrollee currently meets IRF admission criteria under CMS guidelines and is stable to transfer.The Plan denied your request. The Plan says the enrollee does not meet the criteria for IRF services.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the patient requires or can tolerate an 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genesight psychotropic lab testing services provided on December 9, 2019 by an out of network (OON) provider. You asked the Plan to pay for the genesight psychotropic lab testing services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit when provided by an OON provider. 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 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 genesight psychotropic lab testing services provided on December 9, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric hospital services for the enrollee.You asked the Plan to pre-approveinpatient psychiatric hospital services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee has no acute symptoms that require 24-hour 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 relevantMedicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient psychiatric hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee in this case. It is not expected this enrollee would improve in a reasonable period of time for the dates in question as she does not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as the enrollee does not have dangerousness to self or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric hospital services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided on January 21, 2020 and February 19, 2020. You asked the Plan to waive the copayment for the office visits. You say that your specialist copayment is $15. You say that you should be refunded the extra $25. The Plan denied your request. The Plan says the copayments 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 $40 copayment for each Medicare-covered individual therapy session. Covered services include mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws. You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $80 ($40/visit x 2 visits = $80). The office visits fall within the "Outpatient Mental Health Care" benefit category. The records show that psychotherapy was performed during the office visit, which is considered an outpatient mental health service. 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 office visits provided on January 21, 2020 and February 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forknee surgery (27447), laboratory services (82947) and physical therapy (97161) provided on March 18, 2020 through March 19, 2020. We also decided that the Plan does not have to pay for the self-administered drugs. You asked the Plan to waive the copayment forthe knee surgery, laboratory services and physical therapy. You say that you would like reconsideration because you were told you would have a $325 copayment.You also asked the Plan to pay for the self-administered drugs. The Plan denied your request. The Plan says the copayments for these services have been 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 $325 copayment for each Medicare-covered outpatient hospital visit, a $10 copayment for laboratory services and a $40 copayment for outpatient physical therapy. The contract also says that self-administered drugs may be covered under your prescription drug benefit. You have been asked to pay $325 for the outpatient hospital surgery. This means that you have been asked to pay the correct amount based on your contract with the Plan. You have been asked to pay $10 for laboratory services rendered on March 18, 2020 and $7.86 for laboratory services provided on March 19, 2020. This means that you have been asked to pay the correct amount based on your contract with the Plan. You have been asked to pay $40 for outpatient physical therapy services. This means that you have been asked to pay the correct amount based on your contract with the Plan. You have been asked to pay $168.12 for self-administered drugs. Self-administered drugs are not covered under Medicare Part B, but may be covered under your Medicare Part D benefit. 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 forknee surgery (27447), laboratory services (82947) and physical therapy (97161) or pay for the self-administered drugs provided on March 18, 2020 through March 19, 2020.Your complaint about being given incorrect information about your copaymentis 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested psychotherapy services.
You asked the Plan to pre-approve the psychotherapy services. You say that this therapist helped diagnosis your condition and had begun treatment immediately. You say that you felt comfortable with this therapist and you have shown progress in reducing your anxiety condition. The Plan denied your request. The Plan says a transition was provided and there is no evidence of there being clinical reason that one provider will be more effective than another provider with the same credentials. You have not exhausted your option with an in-network provider.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested psychotherapy services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 4, 2020. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 physician's services. 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 physician's services provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power scooter (K0899) provided on January 6, 2020.
You asked the Plan to pay for the power scooter. You say that the power scooter is medically necessary. The Plan denied your request. The Plan says purchase of the scooter was not authorized. The provider it was purchased from is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 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. 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 power scooter (K0899) provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on February 8, 2019.
You asked the Plan to pay for genetic test. You say that this test was requested by the treating physician who determined it was medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this testing is not a covered benefit for the diagnosis listed on the claim.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Without this information, you have not shown that this lab service was ordered or performed for covered purposes. Based on this information, we decided that Medicare rules for coverage of genetic test have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on February 8, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a hip replacement. 
 
You asked the Plan to pre-approve a hip replacement. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hip replacements are covered for certain indications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a hip replacement. Our reviewer says that the documentation does support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee presents with a history of severe right hip pain. Functional mobility limitations are noted. She is using a walker for household ambulation. Clinical exam findings are consistent with radiographic evidence of severe right hip osteoarthritis, including complete joint space loss. She has failed reasonable and/or comprehensive conservative treatment, including activity modification, NSAIDs, and cortisone injection. Under consideration is a request for right total hip arthroplasty. There is radiographic evidence of advanced joint disease, she had failed conservative treatment, and she has persistent severe right hip pain and dysfunction. Medicare coverage criteria have been met to support the medical necessity of total hip replacement for this enrollee. Therefore, this request for right total hip arthroplasty is medically reasonable and 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 a hip replacement have been met. Therefore, we decided that the Plan has to pre-approve a hip replacement.  
 
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on March 11, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel mustbe billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 panel rendered on March 11, 2020.