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

We decided that the Plan does not have to pre-approveHyzaar.You asked the Plan to pre-approveHyzaar. You say that the enrollee has been on this medication for the past several years.The Plan denied your request. The Plan says Hyzaar to be taken 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 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-approveHyzaar.Benefits for Hyzaarmay be available under Medicare Part D.Contactthe 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 pay for ophthalmology services providedon December 26, 2019.You asked the Plan to pay for the ophthalmology services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for theseservices. Therefore, we decided that the Plan does not have to pay for ophthalmology services provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe out-of-network office visit provided on September 29, 2020.You asked the Plan to waive the coinsurance forthe out-of-network office visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an out-of-network office visit on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.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% coinsurance for out-of-network Physician/Practitioner services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an out-of-network office visit provided on September 29, 2020. You have been asked to pay a 30% coinsurance for the out-of-network office visit, totaling $31.99. The out-of-network office visit falls within the Physician/Practitioner 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 coinsurance forthe out-of-network office visit provided on September 29, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe walker, walker seat attachment, commode chair and to pay for the sales tax, bed and furniture square risers, and bedrail support received on May 6, 2020 and June 6, 2020.You asked the Plan to waive the coinsurance forthe walker, walker seat attachment, commode chair and to pay forthe sales tax, bed and furniture square risers, and bedrail support. You say that you were told you would receive 80% of what you spent back.The Plan denied your request. The Plan says the claims have been processed correctly per your plan benefits.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 20% coinsurancefor durable medical equipment. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The furniture risersat 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.The documentation does not support that the bedrail support was considered part of a hospital bed side rail and therefore, is not covered.Sales tax is non-covered. The Plan cannot make payment for Medicare covered services to a provider who does not accept Medicare payment. By purchasing from a provider who does not accept Medicare payment (Amazon.com), you entered a private contract with the provider. You have been asked to pay 20% coinsurance for the walker, walker seat attachment, and the commode chair. 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 forthe walker, walker seat attachment, commode chair and to pay for the sales tax, bed and furniture square risers, and bedrail support received on May 6, 2020 and June 6, 2020
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) stay.You asked the Plan to pre-approvethe SNF stay. You say that the enrollee needs SNF care.The Plan denied your request. The Plan says rules for SNF care have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found although there are identifiable skilled therapy service needs and identifiable skilled nursing needs, the beneficiary does not require skilled nursing or therapy services on a daily basis. In addition, the beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilleWe looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that Medicare rules for coverage of the SNF stay have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) stay.d nursing facility setting.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay provided on April 6, 2017.You asked the Plan to pay forthe SNF stay. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says rules for SNF care have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the SNF stay. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Inaddition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF stay have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) stay provided on April 6, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external catheter system and supplies.
You asked the Plan to pre-approve an external catheter system and supplies. You say that you are paralyzed and cannot go to the bathroom. You say that the medical records provided support the need for the requested external catheter system and supplies. The Plan denied your request. The Plan says Medicare guidelines say that the requested item is not a covered benefit because it is not reasonable and necessary for treatment of an illness or injury, nor is it re-useable. The Plan says that the requested system and supplies are not medical in nature and are used for comfort, hygiene and convenience.
The Plan must follow Medicare rules. Medicare rules say that PDAC determinations are evidence of the correct coding of an item. We looked at the file and Medicare rules. The item was reviewed and is correctly coded as A9270 which is a non-covered item/service. Therefore, we decided that the Plan does not have to pre-approve an external catheter system and supplies.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 28 fractions of proton beam therapy.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says IMRT would be approved if requested.
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 therapy. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found any potential benefit or detriment of proton therapy over standard IMRT for routine cases is an
investigational question.
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 therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve 28 fractions of proton beam therapy.
Appeal type: Other
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvetranscranial magnetic stimulation treatment.You asked the Planto pre-approvethe treatment. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee did not meet the Medicare criteria for coverage.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 treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the criteria for transcranial magnetic stimulation treatment. Her diagnosis is bipolar depression which is not a condition included in the list of approved indications in the Local Coverage Determination.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 treatment have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetranscranial magnetic stimulation treatment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the charge for the radiology services provided on July 22, 2020.You asked the Plan to waive the charge for the diagnostic mammography and ultrasound. You say that deductibles are waived due to the Coronoa-19 pandemic.The Plan denied your request. The Plan says you had not met your deductible at the time of this service.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 there is a $500 deductible for your plan. The item or service you asked the Plan to remove the charge for falls within your plan deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for your plan deductible. This cost sharing is a contractual obligation that had not been met at the time the diagnostic mammography and ultrasound was received on July 22, 2020.The Plan deductible is only waived for in-network primary care, behavioral health and telehealth visits. Therefore, we decided that the Plan does not have to waive the charge for the radiology services provided on July 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approveIRF care. You say that the enrollee needs a hospital level of care for rehabilitation with close medical management and 24-hour nursing oversight. You say that the enrollee's clinical condition meets the full acute inpatient rehabilitation criteria.The Plan denied your request. The Plan says the criteria for coverage of IRF care have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.

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 surgery to repair a hip fracture after a fall. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. 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 documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the cystoscopy provided.

You asked the Plan to waive the co payment for the cystoscopy. You say that this was supposed to be done in the office but was canceled and moved to the hospital. You say that you paid $45 for the procedure at the office and shouldn't be responsible for this copayment.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 $400 copayment for an outpatient hospital facility.

You have been asked to pay a $400 co payment for the cystoscopy. The cystoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the cystoscopy was provided at the hospital. 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 cystoscopy provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on June 25, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you feel that the provider should not be considered a specialist.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 $35 copayment per visit to a specialist.The record shows that the provider you saw on June 25, 2020, is considered a specialist. Therefore, you are responsible to pay the $35 copayment.  You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This meansthat 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 fora specialist visit provided on June 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 12, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory services. You say that your provider performed medically necessary services in good faith.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 has network providers available who can provide the items/servicesat 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 forthe medical services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the full hereditary cancer panel provided on December 11, 2019.
You asked the Plan to pay for the services provided. You say that the records show medical necessity. The Plan
denied your request. The Plan says the records do not substantiate the services.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
We looked at the file and the rules. The records show that the genetic screening test was ordered per the
enrollee's request due to his family history. There are insufficient records to show that the testing was order
due to specific signs or symptoms. The records do not show that the results of the testing would be used to
determine a specific diagnosis or treatment strategy.
The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this test for
screening purposes. Therefore, we decided that the Plan does not have to pay for the full hereditary cancer
panel provided on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services to be provided by an out of network (OON) provider.You asked the Plan to pay forthe KneeRover scooter. You say that the 20% coinsurance should be applied.The Plan denied your request. The Plan says Amazon.com is not considered acertified provider, so it is not covered.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 care that cannot be provided by network providers.The requested device from Amazon.com in this case is not a Medicare certified 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 pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says admission to an inpatient rehab facility is not medically necessary for this patient.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia and their medical conditions are stable. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, or an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. In addition, our doctor found that 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

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-approveacute inpatient rehabilitation facility (IRF) admission and services.