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

We decided that the Plan does not have to waive the copayment for emergency care provided on January 20, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you disagree with the charges because you had a bad reaction to the COVID-19 vaccine and cannot afford the charges. 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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on January 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need therapy. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the records show that you were admitted to the hospital with weakness, confusion, and dehydration. Your current nursing, medical, and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are medically stable with 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. While you may benefit from further therapy, you do not require an intensive therapy program in an IRF and there is not a reasonable expectation that you would be able to fully participate in and benefit from the 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: 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 the stay is medically necessary. 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 the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a stroke the transferred to skilled nursing until March 9, 2021. The patient is now living at
home with ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that this enrollee 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the transthoracic echocardiography (93306) and the myocardial perfusion imaging (78452) provided on December 18, 2020.
You asked the Plan to adjust the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services 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 a $10 copayment for diagnostic procedures and tests provided by your primary care physician. You must pay a $50 copayment for diagnostic procedures and tests performed by a provider other than your primary care physician. Additionally, you pay a 20% coinsurance for diagnostic radiology services other than computed tomography (CT) scans. This cost share applies to services performed by an in-network provider. You have been asked to pay $106.76 which includes a $10 copayment for the diagnostic test and $96.76 for the Plan allowed amount of $483.82 x 20% coinsurance for the diagnostic radiology service 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 cost share for the transthoracic echocardiography (93306) and the myocardial perfusion imaging (78452) provided on December 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
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 available from network providers.
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 a referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelegy Ellipta, 200-62.5-25 MCG/INH aerosol powder.
You asked the Plan to pre-approve Trelegy Ellipta. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 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 Trelegy Ellipta, 200-62.5-25 MCG/INH aerosol powder.
Benefits for Trelegy Ellipta 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an x-ray of the right shoulder.
You asked the Plan to pre-approve x-ray. You say that this is needed to see an orthopedic doctor. The Plan denied your request. The Plan says there was no success in obtaining an order for this x-ray.
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 x-ray. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding any subjective complaints of shoulder pain and/or injury. There are no objective findings provided for review of the right shoulder that would require x-rays to assist in diagnosis and/or treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for x-ray of the right shoulder is not medically reasonable or 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 x-ray have not been met. Therefore, we decided that the Plan does not have to pre-approve an x-ray of the right shoulder.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance.
You asked the Plan to pre-approve Jardiance. You say that alternatives are not appropriate for this enrollee. The
Plan denied your request. The Plan says Jardiance to be administered at home is not covered under the Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Jardiance.
Benefits for Jardiance 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that these are medically necessary to
improve your quality of life. The Plan denied your request. The Plan says these are non-covered items.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 A6549.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the dental services you received on June 11, 2020.
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the general anesthesia was covered at 100 percent and the extractions were covered at 50 percent per your contract with the Plan. The Plan says that dental code D0001 is not covered under your Plan's supplemental dental 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. We looked at the file, the Plan's contract and Medicare rules. The file shows that the Plan covered the anesthesia services at 100 percent and the extractions at 50 percent per the Plan's contract. Though the Plan offers this supplemental dental benefit, dental code D0001 is not covered under this supplemental benefit. Therefore, we decided that the Plan does not have to pay additionally for the dental services you received on June 11, 2020.
Your complaint about the contracted provider not refunding you more is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on June 29, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 80307 and HCPCS G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy, implanted pump pain management
infusion (CPT code S9328).
You asked the Plan to pay for the services. You say that the services are medically necessary. The Plan denied
your request. The Plan says the services are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the services have not been met. This
coding is not valid for Medicare purposes. We are unable to determine the payment for this code (S9328).
Payment for this service as your provider has coded it is not a covered benefit under your Medicare and
medical plan. Therefore, we decided that the Plan does not have to pay for home infusion therapy, implanted
pump pain management infusion (CPT code S9328).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 27, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the provided records do not contain sufficient information to determine the medical necessity or reasonableness of the requested service 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 laboratory services provided to the enrollee on July 27, 2020.
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 the additional trips. You say that you need more rides to continue physical therapy. The Plan denied your request. The Plan says this request 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 24 one-way 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 additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from November 15, 2020, to November 17, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you do not believe you should be held responsible for paying for the self-administered drugs. The Plan denied your request. The Plan says self-administered drugs are not covered by Medicare 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 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 pay for the self-administered drugs provided from November 15, 2020, to November 17, 2020.
Benefits for the self-administered drugs 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for home physical therapy services (CPT 97530) provided to the enrollee on July 2, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 97530-GO CO KX (4 units) remains 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 97530 is "therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes." 

We asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the home visit was performed by a Certified Occupational Therapy Assistant (COTA). CPT 97530 is an incorrect code to report for COTA. There is a more appropriate code to report for services performed by a occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. 

We looked at this coder'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 home physical therapy services (CPT 97530) provided to the enrollee on July 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis  0.05%.

You asked the Plan to pre-approve Restasis  0.05%. The Plan denied your request. The Plan says Restasis  0.05% is not a Part B drug. The enrollee's Plan does not include Part D prescription drug coverage.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.

We looked at the file and the Medicare rules. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. The Plan says that the enrollee's Plan does not include Part D coverage. Therefore, we decided that the Plan does not have to pre-approve Restasis  0.05%.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, K0108, E2377, E2313, E2311) for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options.
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 the accessories. Our reviewer says that
the requested additional accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the E2300 seat elevator and the K0108 bag do not serve a primary medical need and are not medically necessary. Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to feed himself indicates that the enrollee can control any power options through their own individual switches. 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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2300, K0108, E2377, E2313, E2311) for the enrollee.