Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on August 4, 2020. You asked the Plan to pay for the hearing aids. You say that this should be covered. The Plan denied your request. The Plan says this was not purchased from a network provider. Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by a Plan provider. We looked at the file and the Plan's rules. The file indicates you did not receive the hearing aids from a Plan provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on August 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you felt that a private room was safer due to your health conditions. 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 $200 copayment for days 1-7 for inpatient hospital care.

You had an inpatient hospital stay. Therefore, you are responsible to pay a $200 copayment for days 1-6. $200 (copayment) x 6 (inpatient days) = $1,200.

You have been asked to pay the total copayment amount of $1,200 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral evaluation (D0140) and intraoral radiographic imaging (D0220) provided on October 19, 2020.
You asked the Plan to pay for the dental services. You say that you did not receive all of the services that were billed and only went in for an extraction. The Plan denied your request. The Plan says the dental provider confirmed that these services were performed. The services in question are not covered by Medicare or by your Plan's supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the oral evaluation (D0140) and intraoral radiographic imaging (D0220) provided on October 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on December 14, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not feel like you should have to pay for this. You say that you had a bad reaction to the injection. The Plan denied your request. The Plan says the correct coinsurance 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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $1,216. The total amount you are being asked to pay is $243.20 ($1,216 x 20% = $243.20). An injection falls within the Medicare Part B prescription 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 an injection provided by a participating provider on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399).
You asked the Plan to pre-approve the seat lift mechanism. You say that the seat lift mechanism is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 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 seat lift mechanism. Our reviewer says that the seat lift mechanism is not medically necessary. Our physician reviewer found the medical records provided do not state that the patient is completely incapable of standing from a normal chair in the home. 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 seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627, E1399).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient diagnostic services provided on June 1, 2020.
You asked the Plan to pay for the outpatient diagnostic services. You say that the services you received are not related to hospice or for the purpose of hospice. You say that were advised by your provider that they were working on getting the services covered. You also say that you were not aware that the claim had not yet bet paid. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the outpatient diagnostic services provided on June 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need the orthotics to compensate for height
imbalance. The Plan denied your request. The Plan says the services are not covered.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the pelvis x-ray provided on October 28, 2020.
You asked the Plan to pay for the pelvis x-ray. You say that the enrollee was referred to you by a participating provider. The Plan denied your request. The Plan says that the enrollee was referred by a non-participating provider. The Plan also says that prior authorization was not obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document, but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that the Plan has to pay for the pelvis x-ray provided on October 28, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occupational therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve occupational therapy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 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 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 occupational therapy to be provided by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on November 26, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that you were under the impression there were no copayments when you signed up for this plan. You say that you are on a fixed income and it is hard to cover unexpected fees. The Plan denied your request. The Plan says the copayment 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 $90 copayment for emergency care. Cost-sharing is waived if you are admitted to the hospital. You have been asked to pay a $90 copayment for the ER visit. The ER visit 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 the ER visit provided on November 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), evaluation (D0150) and bitewing x-rays (D0274) provided on October 22, 2020, by an OON provider. You asked the Plan to pay for the dental services. You say that you believed this provider was in the Plan's network, and you received confirmation from the provider that they accept payment from this Plan. The Plan denied your request. The Plan says the supplemental dental benefit does not cover services provided out of network. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110), evaluation (D0150) and bitewing x-rays (D0274) provided on October 22, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that you saw this in a commercial and would like to measure your glucose without getting pricked every time. The Plan denied your request. The Plan says you are not insulin-treated.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services (97110, 97161, 97162, 97163) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON physical therapy services. You say that you don't want to start going to a new facility. The Plan denied your request. The Plan says the requested services are available in-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 physical therapy services (97110, 97161, 97162, 97163) to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve lumbar fusion multi-level (low back surgery). You asked the Plan to pre-approve lumbar fusion multi-level. You say that you do not understand why your spinal surgery has been denied. You did all the requirements including physical therapy several times. The surgery was scheduled November 18, 2020 but due to COVID it was cancelled. The Plan denied your request. The Plan says that the information provided does not support the requirements of NIA's medical necessity clinical guidelines. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar fusion multi-level. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether a multi-level lumbar fusion for this enrollee is a covered service under Medicare rules. In the absence of a national or local coverage determination, the Social Security Act, Section 1862 (a)1(A) and the 42 CFR Section 411.15(k) defines the medical necessity and reasonableness of the requested service. The provided documentation demonstrates disease by imaging with trial injections that show improvement. The documentation indicates that the enrollee has failed conservative therapy including physical therapy. The requested services are medically reasonable and necessary. The requested service is recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion multi-level have been met. Therefore, we decided that the Plan has to pre-approve lumbar fusion multi-level (low back surgery). 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical pathology (88305) provided on September 23, 2020.
You asked the Plan to pay for surgical pathology. You say that this is supported in the records. The Plan denied your request. The Plan says only one unit is supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 88305 are not supported in the medical record. The medical record only supports 1 unit of CPT code 88305. Based on this information, we decided that Medicare rules for coverage of surgical pathology have not been met. Therefore, we decided that the Plan does not have to pay for surgical pathology (88305) provided on September 23, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic testing services provided on January 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the plan made a mistake. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available to provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the ophthalmic testing services provided on January 23, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care, first hour, provided on September 12, 2020.
You asked the Plan to pay for the physician service. You say that the enrollee was seen by 2 different providers with 2 different specialties on the date of service. You say that both providers charged out CPT code 99291. You also say that this service should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 critical care, first hour, provided on September 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 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 enrollee does not meet the criteria for coverage. The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The records show that the enrollee is not insulin treated. 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 continuous glucose monitor (CGM).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID infection, deep vein thrombosis and a urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.