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

We decided that the Plan does not have to pre-approve a heavy-duty power scooter with upgraded batteries
(K0801, K0108).

You asked the Plan to pre-approve the scooter. You say that a manual wheelchair does not allow for adequate
mobility. The Plan denied your request. The Plan says the submitted documentation indicates that your weight
is 184 pounds; and the use of upgraded batteries is for use outside of home and leisure.

The Plan must follow Medicare rules. Medicare rules say that K0801 is intended for patients in a weight range of 301 to 450 pounds. 

Your weight is 184 pounds, which is not within the weight range for the requested scooter. Additionally, the batteries would not be covered as they are a convenience item intended for use outside of the home. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power scooter with upgraded batteries (K0801, K0108).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an inpatient hospital stay. We decided that the Plan does not have to reduce the cost-sharing charges for an inpatient hospital stay to the amount you requested.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were told that inpatient copayments were waived due to COVID-19. The Plan says that the claims were processed correctly, and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for an inpatient hospital stay from $2,010 to $1,925.
Your contract with the Plan clearly says that enrollee's must pay a $385 copayment for days 1-5 for inpatient hospital care. The Plan says that you must pay $2,010 for an inpatient hospital stay. However, based on your contract with the Plan, you cannot be asked to pay more than $1,925 for the inpatient hospital stay. Therefore, we decided that the Plan has to reduce the cost-sharing charges for an inpatient hospital stay from $2,010 to $1,925.
We also decided that the Plan does not have to reduce the cost-sharing charges for an inpatient hospital stay to the amount you requested.
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 $385 copayment for days 1-5 for an inpatient hospital stay.
You had an inpatient hospital stay from January 13, 2021, to January 19, 2021. This inpatient hospital stay does not qualify for the COVID-19 copayment waiver. Therefore, you are responsible to pay a $385 copayment for days 1-5 (January 13, 2021, to January 17, 2021). The total amount you owe is: $385 (copayment) x 5 (inpatient days) = $1,925.
Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from January 13, 2021, to January 19, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Androderm patches for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Androderm patches for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the thorax, creatinine, and low osmolar contrast material provided on October 19, 2020.

You asked the Plan to pay for the CT of the thorax, creatinine, and low osmolar contrast material. You say that this claim has not been paid in full or under the terms of the contract for the services provided to this enrollee. 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 enrollee's terminal condition.

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 the CT of the thorax, creatinine, and low osmolar contrast material provided on October 19, 2020.
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 you need rehab for your fractured hip. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily therapy.

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 physician reviewer found that you were admitted to the acute care hospital for surgical repair of a hip fracture after a syncopal fall. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on August 24, 2020.

You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that the requested item was a necessity for the enrollee's care. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis (DVT) or pulmonary embolism (PE).

The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers. 

The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and pneumatic appliance (E0673) provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses (V2797) purchased February 11, 2021, and the sales tax charged on January 25, 2021, and February 11, 2021.

You asked the Plan to pay for the eyeglasses purchased February 11, 2021, and the sales tax for your eyeglass purchases.. You say that this is a covered benefit. The Plan denied your request. The Plan says one pair of eyeglasses following cataract surgery has already been covered therefore the second pair is not eligible for coverage. Additionally, the Plan says that sales tax is not a covered item.

The Plan must follow Medicare rules. The Plan covers one pair of eyeglasses after each cataract surgery that includes insertion of an intraocular lens. If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery. 

We looked at the file and the Plan's rules. The Plan provided documentation showing that one pair of eyeglasses was covered on January 25, 2021, following your cataract surgery. Sales tax is not listed as a covered item. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2797) purchased February 11, 2021, and the sales tax charged on January 25, 2021, and February 11, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to adjust the copayment for the knee surgery you had on January 19, 2021.

You asked the Plan to adjust the procedure. You say that the copayment should only be $95. The Plan denied your request. The Plan says that you have been asked to pay the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $95 copayment for outpatient surgery at an outpatient hospital. 

The Plan says you must pay a $108.20 copayment for the procedure. Based on the Plan contract, however, you cannot be asked to pay more than a $95 copayment for the procedure. Therefore, we decided that the Plan has to adjust the copayment to $95 for the knee surgery you had on January 19, 2021.

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: 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 you need physical therapy to avoid future falls. The Plan denied your request. The Plan says you do not need an intensive rehab program.
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 physician reviewer found that you were admitted to the acute care hospital for surgical treatment of a hip fracture. You were discharged home. Your medical conditions are stable. You do not require treatment by multiple therapies in an intensive rehab therapy program. You do require physical, but there is no documented need for an intensive rehab program.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on
February 17, 2021.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that to avoid the danger of
taking another fall you purchased a lighter weight portable oxygen concentrator. The Plan denied your request.
The Plan says oxygen equipment is rental and not covered for purchase.
The Plan must follow Medicare rules. The rules say that only rented oxygen equipment is eligible for coverage.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not
have to reimburse you for the portable oxygen concentrator purchased on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the patient does not require services at the LTACH that are not already available at
the current facility.

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. Specifically, the LTACH does not
offer any medically necessary services for this patient that they are not already receiving at their current level
of care. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electroencephalography (EEG) monitoring with video to be rendered by the out of network (OON) provider.

You asked the Plan to pre-approve this service. 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 service.

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 service at issue in this appeal.

We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve electroencephalography (EEG) monitoring with video to be rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on November 4, 2020.

You asked the Plan to waive the copayment for urgently needed services. You say that you only went to get a prescription and should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for urgently needed services. 

You have been asked to pay a $30 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on November 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroplasty surgery to be rendered by the
out of network (OON) provider.

You asked the Plan to pre-approve this service. 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 service.

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 service at issue in this appeal. We found no exception that would require the
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a total knee
arthroplasty surgery to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on March 22, 2021.

You asked the Plan to pay for the eye refraction. You say that these services were necessary for your medical
condition. The Plan denied your request. The Plan says they have agreed to cover the eye exam, however eye
refractions are not covered by Medicare or by the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and
eyewear.

The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we
decided that the Plan does not have to pay for the eye refraction (92015) provided on March 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound provided on January 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for an ultrasound. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there are in-network providers available for these 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 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 an ultrasound provided on January 8, 2021 by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87591,
87640, 87641, 87653, 87798) provided on October 1, 2020.

You asked the Plan to pay for laboratory services. You say that this should be covered as an in-network service.
The Plan denied your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87591, 87640, 87641, 87653, 87798) provided on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on January 25, 2021 by an out of network (OON) provider.

You asked the Plan to pay for pathology services. 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 a participating 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 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 pathology services provided on January 25, 2021 by an out of network (OON) provider.
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 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the patient does not require services at the LTACH that are not already available at the current facility. 

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. Specifically, the LTACH does not offer any medically necessary services for this enrollee that they are not already receiving at their current level of care. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.