Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the evaluation states that a group 2 power wheelchair is more appropriate.
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 power scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found you are not shown to require or to be able to safely operate the requested power scooter. There were multiple telemedicine office visit notes submitted, but there are no therapy or wheelchair evaluations.
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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Hyaluronan injection you received on March 3, 2021.
You asked the Plan to waive the coinsurance for the Hyaluronan injection. You say that you believes this would be covered in full. You said you were never told there would be a cost to you and you are on a fixed income. The Plan denied your request. The Plan says you were charged this coinsurance 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 Medicare Part B-covered drugs. You have been asked to pay 20% coinsurance for the Hyaluronan injection. The Hyaluronan injection falls within the Medicare Part B-covered 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 Hyaluronan injection you received on March 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 4, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were evaluated and treated by the emergency medical service. You also say that when they asked if you wanted to go to the hospital, you declined and signed the waiver stating you did not want to go. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on April 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octagam injection (J1568).
You asked the Plan to pre-approve Octagam; Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg (J1568). You say that given the enrollee's history of recurrent infections and low Immune Gama Globulin (IgG) level this drug is medically necessary. The Plan denied your request. The Plan says there is no information that shows the enrollee has a problem with building immunity after vaccines or a history of severe recurrent infections
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Octagam; Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg (J1568). Our reviewer says that the drug is not medically necessary. Our physician reviewer found although the patient has IgG that is low, he does not meet the established from his health plan. He only has 1-2 infections per year that are decreasing and no documentation that prophylaxis has been tried and he has response to vaccines. The use of IVIG is not reasonable or 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 Octagam; Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg (J1568) have not been met. Therefore, we decided that the Plan does not have to pre-approve Octagam injection (J1568).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for occupational therapy provided from February 10, 2019, through February 19, 2019.
You asked the Plan to waive the copayment for occupational therapy. You say that the insurance company exhausted their payments before the bill arrived. You say that you do not understand why the Plan is refusing to honor this bill. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $20 copayment for each Medicare-covered occupational therapy visit.
The enrollee has been asked to pay a $20 copayment for each occupational therapy visit. The total amount you owe is $140 ($20/visit x 7 visits = $140). Occupational therapy falls within the "Outpatient Rehabilitation Services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for occupational therapy provided from February 10, 2019, through February 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on January 29, 2021.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on January 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested 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 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 office visits to be rendered by the out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 1, 2021, through February 19, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for SNF services provided from February 1, 2021, through February 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on February 16, 2021 by an OON provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that authorization was impossible to obtain due to the enrollee misleading you with the incorrect insurance information. You also say that the treating provider is not responsible for requesting authorization for a Medicare enrollee to whom he renders services. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that these services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit provided on February 16, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical 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 the requested services. Our physician reviewer found that the enrollee has chronic low back pain with radiation to his thighs. An EMG confirmed a chronic L5 radiculopathy on the right. He has tried medical therapy and physical therapy. The review has determined that the records do not show that the coverage criteria for the requested injections have been met.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection, diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral, single level (64494, RT/ LT) provided February 26, 2021.
You asked the Plan to pay for the injection. You say that please see attached to support and reprocess line item 64494-50, 79 to pay according to your contract. The Plan denied your request. The Plan says the units exceed the Medicare unlikely edits.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494-RT/LT, 79 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for injection, diagnostic or therapeutic agent, paravertebral facet joint, with image guidance, lumbar or sacral, single level (64494, RT/ LT) provided February 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth extraction (D7210), and a comprehensive oral examination (D0150).

You asked the Plan to pre-approve a tooth extraction and oral exam. You say that the service is medically necessary. The Plan denied your request. The Plan says dental services must be performed by a participating general dentist. Dental services performed by an oral surgeon are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a tooth extraction (D7210), and a comprehensive oral examination (D0150).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic parenteral drug (D9610) provided on March 24, 2021.
You asked the Plan to pay for a therapeutic parenteral drug. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a therapeutic parenteral drug (D9610) provided on March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transportation services (A0428) provided on December 20, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you feel this copayment should be waived because it was related to COVID-19. The Plan denied your request. The Plan says this ambulance trip was not related to COVID-19, and this claim was processed 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 Medicare-covered ambulance services. You have been asked to pay a $308.23 copayment for ambulance services. You argue that this service was related to COVID-19. While there is an ongoing public health emergency, some changes have been made to certain services. However, in the case of ambulances, this pertains to covered destinations and a temporary expansion of coverage criteria. This does not affect the contractual cost-sharing for Medicare-covered ambulance 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 waive the copayment for the non-emergency ambulance transportation services (A0428) provided on December 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided February 7, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you should be able to take transportation when you feel sick. The Plan denied your request. The Plan says the copayment has 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 $260 copayment for each one-way Medicare-covered ground ambulance trip. You have been asked to pay a $260 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 service, basic life support, emergency transport (A0429) provided February 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fillings (D2332 x 4) provided on March 11, 2021.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says fillings are not listed as covered services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fillings (D2332 x 4) provided on March 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have any documented skilled nursing needs and you do not require skilled therapy on a daily basis at an inpatient level. 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from February 3, 2020, to February 12, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that these services should be covered in full by Medicare. The Plan denied your request. The Plan says this claim was processed, and your cost-sharing has been applied correctly. You are responsible for a $370 copayment for each of the first five days of a Medicare-covered hospital stay. There is a $0 copayment for additional Medicare-covered days. You were charged a lesser amount than the contractual copayment because you met your out-of-pocket maximum during your stay.
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 $370 copayment for each of the first five days of a Medicare-covered hospital stay. There is a $0 copayment for additional Medicare-covered days. You pay these amounts until you reach the out-of-pocket maximum, which is $3,900 for your Plan. You have been asked to pay a $474.77 copayment for the inpatient hospital care provided from February 3, 2020, to February 12, 2020. The maximum copayment you could be charged for an inpatient hospital admission of five days or more is $$1,850 ($370 copayment x 5 days = $1,850). Documentation shows that you met your out-of-pocket maximum for the year after this bill of $474.77, so the Plan has charged you this amount for the services rather than the full copayment. 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 admission and services provided from February 3, 2020, to February 12, 2020.