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

We decided that the Plan does not have to waive the copayments for the telehealth visit you had with an anesthesiologist on January 29, 2021, the telehealth visit you had with your primary care provider (PCP) on February 19, 2021, and the telehealth visit you had with an orthopedist on March 2, 2021.
You asked the Plan to waive the copayments for the telehealth visits. You say that you were not aware that there was a change to the zero-copay benefit for phone calls. In addition, you said that after the telehealth visit with the orthopedist, you cancelled the surgery, so you should not have to pay the copayment. The Plan denied your request. The Plan says you were charged these copayments 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 telehealth visits with a specialist and a $10 copayment for telehealth visit with a primary care provider. You have been asked to pay a $40 copayment for the telehealth visits you had with the anesthesiologist and the orthopedist. Both of these providers are specialists. In addition, you have been asked to pay a $10 copayment for the telehealth visit you had with your primary care provider. These copayments apply regardless of your satisfaction with the service received. 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 copayments for the telehealth visit you had with an anesthesiologist on January 29, 2021, the telehealth visit you had with your primary care provider (PCP) on February 19, 2021, and the telehealth visit you had with an orthopedist on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that this service was medically necessary.
The Plan denied your request. The Plan says rules for inpatient care have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the patient is a 73-year-old male who presented to the emergency department with
right-sided weakness on his face. Imaging services provided showed recent stroke. Evaluation recommended
no additional therapy as symptoms and walking was normal. Based on the initial workup, hemodynamic
stability, and spontaneous symptom resolution on admission, it was not expected that the patient would have
required hospital services that would have likely crossed 2 midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty walker.
You asked the Plan to pre-approve a heavy-duty walker. You say that you have already been authorized two other heavy-duty walkers by the brakes go out quickly and you need to get new ones. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker is covered for enrollees who meet coverage criteria for a standard walker and who weigh more than 300 pounds. We looked at the file and Medicare rules. Review of the file does not support that you weigh more than 300 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair ramp (E1399).
You asked the Plan to pre-approve a wheelchair ramp. You say that existing and entering your home is necessary and a single ramp is not adequate for safety reasons. You find it medically necessary he have two rams for his home. The Plan denied your request. The Plan says home modifications are not a covered benefit. Ramps are for use outside the home and do not serve a medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair ramp (E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided by an out-of-network provider on December 30, 2020.
You asked the Plan to pay for the pathology services. You say that the patient's healthcare provider took the specimens at their office and sent them to the laboratory for analysis. You say that the claim should be reconsidered for payment as the billed service was referred by an authorized provider. The Plan denied your request. The Plan says prior authorization was not obtained.
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 pathology services provided by an out-of-network provider on December 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Narcan 4mg nasal spray.

You asked the Plan to pre-approve the spray. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is intended for patient self-administration.

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 Narcan 4mg nasal spray.
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 going to a nursing home will not give you the adequate therapy and rehabilitation needed to recover from your fall. 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 non-surgical management of pelvic fractures after a fall. 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: 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 enrollee needs to go to the hospital to get better. The Plan denied your request. The Plan says the enrollee does not have a complex condition that requires further hospital care.
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 physician reviewer found that the enrollee was admitted to the acute hospital following heart surgery complications. He currently requires supplemental oxygen via trach mask, feeding via PEG tube, and routine respiratory therapy. The enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not 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 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 pre-approve a power wheelchair and accessories.
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested items.
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.
The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your condition can be improved by a walker, cane or manual wheelchair, or you cannot safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $300 to $75 for the esophagogastroduodenoscopy, with biopsy (43239) provided on February 16, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $300 copayment for each Medicare covered outpatient surgery or procedure at an outpatient hospital facility or ambulatory surgical center.
You have been asked to pay a $300 copayment for the outpatient surgery provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the copayment from $300 to $75 for the esophagogastroduodenoscopy, with biopsy (43239) provided on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a car seat (E1399).
You asked the Plan to pre-approve a car seat. You say that this item should be reconsidered as DME as he needs to have safety in the car. He needs to keep himself up because he is unable to be stable in a vehicle when going to specific appointments. The Plan denied your request. The Plan says the requested car seat is not considered durable medical equipment and is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a car seat (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) you had at an
outpatient hospital facility on April 1, 2021.

You asked the Plan to waive the copayment for the EKG. You say that you paid much less for this service in
the past and you believe the charges are incorrect. The Plan denied your request. The Plan says you were
charged this copayment correctly. The Plan says that because the allowed amount for this service ($49.76) is
less than your copayment, you are responsible for the full allowed 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 a $50
copayment for diagnostic procedures and tests at an outpatient hospital facility.

You have been asked to pay a $50 copayment for the EKG. The EKG falls within the diagnostic procedures
and tests at an outpatient hospital facility benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for the electrocardiogram (EKG) you had at an outpatient hospital facility on April 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair upgraded electronics or the bag.
You asked the Plan to pre-approve power wheelchair expandable controller (E2377), power wheelchair
expandable controller harness (E2313), power wheelchair electronic connection (E2311) and bag (K0108). You
say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The
Plan says there is not a medical need to control the power options through the joystick.
The Plan follows Medicare rules. Medicare rules say that options and accessories for wheelchairs are covered if
the beneficiary has a wheelchair that meets Medicare coverage criteria and the option/accessory itself is
medically necessary.
The file shows that the enrollee has adequate upper limb strength and function to control the power options
using their own switches which are included in the allowance of the power options. The bag at issue in this
appeal (K0108) does not serve a purpose that is primarily medical in nature. This means that Medicare rules for
coverage of upgraded electronics and bag have not been met. Therefore, we decided that the Plan does not have
to pre-approve power wheelchair upgraded electronics or the bag.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Fluid Flow injection.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic knee pain from osteoarthritis. The requested Fluid Flow injection is considered experimental/investigational in nature and not 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat Fluid Flow injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a service dog (S5199).
You asked the Plan to pre-approve a service dog. You say that having a service dog is a medical necessity. You say that you need coverage for food and medical services for the service dog. You also say that your doctor advised that you qualify for service dog support. The Plan denied your request. The Plan says you do not meet the qualifying criteria for this benefit.
Medicare generally does not cover service dog services. However, the Plan offers a special supplemental benefit for the chronically ill (SSBCI) that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a service dog have not been met. Specifically, the record does not show that you qualify under the ADA for the service dog. Therefore, we decided that the Plan does not have to pre-approve a service dog (S5199).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you have not had a change in function that needs daily skilled therapy services.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on December 20,
2020.
You asked the Plan to pay for the paramedic intercept services. You say that you were unaware of two
companies being involved for this service. The Plan denied your request. The Plan says this item is not a
covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the
paramedic intercept services provided on December 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided by a participating provider on January 13, 2021.
You asked the Plan to waive the copayment for a specialist telehealth visit. You say that this was a telehealth visit. You say that you should not have a copayment for this because of Covid-19. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for physician/practitioner services/telehealth/specialist. You have been asked to pay a $20 copayment for a specialist telehealth visit. The correct copayment has been applied to the telehealth visit that were provided. A specialist telehealth visit falls within the
physician/practitioner services/telehealth/specialist 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 a specialist telehealth visit provided by a participating provider on January 13, 2021.