Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-shares for an office visit (99214), a compounded drug (J7999) and an eye injection (67028) provided on January 14, 2021.

You asked the Plan to waive the cost-shares for an office visit, a compounded drug and an eye injection. You say that you receive a shot in your right eye every month and you feel the Plan should pay for it. The Plan denied your request. The Plan says the cost-shares 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 there is a $750 deductible for your covered medical services. Your contract with the Plan also clearly says that you must pay a $35 copayment for physician/practitioner services, including doctor's office visits. Your contract with the Plan also clearly says that enrollees must pay a 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $35 copayment for an office visit, a 20% coinsurance for a compounded drug and $110.99 towards your deductible for an eye injection.

The EOC confirms that $35 is the required copayment for an office visit.

You have been asked to pay a 20% coinsurance for Medicare Part B drugs. The allowed amount of the claim for the compounded drug is $156, resulting in a coinsurance obligation of $31.20.

The service at issue is also subject to the Plan deductible of $750. The record shows that at the time this claim was processed, $0 of the $750 deductible had been met. The allowed amount for the eye injection is $110.99, resulting in a deductible obligation of $110.99.

Your total cost-share amount is $177.19 ($35 + $31.20 + $110.99 = $177.19). This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost-shares for an office visit (99214), a compounded drug (J7999) and an eye injection (67028) provided on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy services rendered from September 22, 2020 to February 9, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you have to see an out-of-network provider. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Part B drugs, including chemotherapy drugs.
Review of the file shows that you received chemotherapy services from September 22, 2020 to February 9, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Part B drugs, including chemotherapy 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 chemotherapy services rendered from September 22, 2020 to February 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the excision of buttock lipoma.

You asked the Plan to pre-approve the excision of buttock lipoma. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that excision of skill will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision. 

We looked at the file and Medicare rules. In this case, there is no other surgery being done at the same time. Based on this information, we decided that Medicare rules for coverage of the excision of buttock lipoma have not been met. Therefore, we decided that the Plan does not have to pre-approve the excision of buttock lipoma.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.

You asked the Plan to pre-approve a power wheelchair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a power wheelchair. Our reviewer says that the requested item is not medically necessary in this case. Our physician reviewer found that the documentation states the enrollee has a personal mobility deficit that impairs participation in MRADLS. The documentation does not reveal a detailed musculoskeletal and neuromuscular exam that indicates why the enrollee is unable to effectively ameliorate the mobility deficit with a walker or manual wheelchair. It is not clear that the enrollee can safely maneuver the requested power wheelchair in the home and that the power wheelchair will significantly improve MRADL participation. The criteria for the power wheelchair have not 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 a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care (99233) provided April 20, 2020.

You asked the Plan to pay for subsequent hospital care. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the Medicare hospice care benefit would be responsible for this payment.

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 subsequent hospital care (99233) provided April 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the center mount power elevating leg rests (E1012).

You asked the Plan to pre-approve the center mount power elevating leg rests. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a power elevating leg rest is subject to the criteria listed 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 the center mount power elevating leg rests. Our reviewer says that the requested equipment is not medically necessary. Our physician reviewer found the requested power elevating leg rests appear to exceed the patient's medical need. The documentation does not indicate that the patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or has significant edema of the lower extremities that requires an elevating legrest; or meets the criteria for and has a reclining back on the 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 center mount power elevating leg rests have not been met. Therefore, we decided that the Plan does not have to pre-approve the center mount power elevating leg rests (E1012).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea (J0178) for the enrollee.

You asked the Plan to pre-approve Eylea. You say that the drug is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the step therapy requirements for this drug.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Eylea. Our reviewer says that the service is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Avastin before they will approve the requested drug. In this case the patient has tried and not failed the required drug. The enrollee has had four intraocular injections with Avastin with an improved eye exam compared to prior, there visual acuity is stable, and there is no evidence of subretinal fluid. Eylea is recommended due to the enrollee's recent stroke. However, the incident rate of systemic side effects such as stroke is low, and it is consistent across all anti-VEGF (Eylea and Avastin). There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Specifically, there is no evidence that the required step therapy drug would be less effective than the requested. This means the requested drug is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve Eylea (J0178) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you have an appointment and do not 
drive. The Plan denied your request. The Plan says the denial of authorization for additional routine 
transportation, because routine transportation beyond 60 one-way trips per calendar year is not covered by the 
Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.

We looked at your request, the records in the case file, and the rules. At the time the Plan sent your case to us, 
you had used 58 of the 60 one-way trips covered by the Plan. When 60 trips have been utilized, the Plan's 
routine transportation benefit will be exhausted. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6537.
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary.
The Plan denied your request. The Plan says the item is not covered because it does not meet the statutory
definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6537 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6537.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed (E0260). You say that you meet criteria because of your medical conditions. The Plan denied your request. The Plan says the medical records do not show why you need frequent changes in body position or immediate need for a change in body position.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed (E0260). Our reviewer says that the review has determined that the medical records do not document why the enrollee needs frequent changes in body position or immediate need for a change in body position. Our physician reviewer found the patient's condition does not require position of the body in ways not feasible in an ordinary bed. The patient does not require frequent changes in body position. There will not be a need for immediate changes in body position. The patient's condition does not require special attachments that cannot be fixed and used on an ordinary bed. The requested semi-electric hospital bed is not medically necessary for this patient. 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 semi-electric hospital bed (E0260) have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on March 22, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly

The Plan must follow Medicare rules. Medicare rules say that services rendered to an inpatient must be billed with Place of Service (POS) code 21. 

We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the date of service at issue and the claim was not billed with the required POS code 21.

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 for the magnetic resonance imaging (MRI) rendered on March 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on April 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility."
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 services. Our reviewer says that the use of code 97110 is not supported by the records provided. Our physician reviewer found that the documentation supports services were performed in the enrollee's home; therefore, a Healthcare Current Procedure Coding System (HCPCS) code should be reported for the services performed. CPT code 97110 would not be covered in this case. 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 pay for the services (97110) provided on April 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility services provided February 8, 2021, to February 11, 2021.
You asked the Plan to waive the copayment for the skilled nursing facility services. You say that you were told the service would be covered. 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 $184 per day copayment for days 21 to 46 of Skilled Nursing Facility services.
You have been asked to pay a $736 copayment for 4 days of skilled nursing care ($184 per day). 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 skilled nursing facility services provided February 8, 2021, to February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on October 23, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.

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 lab work provided on October 23, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided September 25, 2019, to October 1, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $295 per day copayment for days 1-7 for inpatient care.
You have been asked to pay a $1,770 copayment for 6 days of inpatient care ($295 per day). 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 inpatient hospital care provided September 25, 2019, to October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency taxi transportation (A0100).

You asked the Plan to pre-approve non-emergency taxi transportation. You say that you cannot afford to pay for alternative transportation. The Plan denied your request. The Plan says you have exhausted your transportation benefit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve non-emergency taxi transportation (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gastroenterology office visits to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the gastroenterology the office visits. You say that you are appealing this denial. The Plan denied your request. The Plan says the provider 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the gastroenterology office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs to your power wheelchair.
You asked the Plan to pre-approve repairs to your power wheelchair. You say that these repairs are necessary for the wheelchair's function. The Plan denied your request. The Plan says payment cannot be made for repairs due to misuse.
The Plan must follow Medicare rules. Medicare rules say that cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment should be investigated and denied. We looked at the file and Medicare rules. In this case, the medical records indicate that the repairs are neded because of the abuse of the equipment in question and not due to normal wear. Based on this information, we decided that Medicare rules for coverage of repairs to your power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs to your power wheelchair.