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

We decided that the Plan does not have to pre-approve foot orthotic inserts.
You asked the Plan to pre-approve foot orthotic inserts. You say that you have tried everything you can and nothing helps. The Plan denied your request. The Plan says this item is not a covered benefit.
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 orthotic inserts.
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving appropriate care in the current setting.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 there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total electric hospital bed.You asked the Plan to pre-approvea total electric hospital bed. You say that in order to get outof bed the enrollee needs to have the bed low to the floor.The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvea total electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided, on October 16, 2019.
You asked the Plan to pay for the panoramic x-ray (D0330). You say that this amount is not your responsibility because the dentist office did the procedure without notice to you. The Plan denied your request. The Plan says the service is not a covered 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 panoramic x-ray (D0330) is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on October 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 12, 2019 through June 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. The initial treatment plan could have been carried out with the enrollee in the outpatient/observation setting Inpatient admission was not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 12, 2019 through June 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on August 26, 2019.You asked the Plan to waive the copayment fora colonoscopy. You say that you were charged because biopsies were taken and disagree.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 $275 copayment for surgical services provided in an ambulatory surgical center.The record shows that you had biopsies taken during a colonoscopy on August 26, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $275 copayment.  You have been asked to pay a $275 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora colonoscopy provided on August 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neuropsychological testing.You asked the Plan to pre-approve the Neuropsychological testing. You say that this test is medically necessary as the member is suffering from cognitive decline. The Plan denied your request. The Plan says the documentation fails to identify how the testing will impact management The Plan follows Medicare rules. Medicare rules say that hospital outpatient psychiatric services must be for the purpose of diagnostic study or the services must reasonably be expected to improve the patient's condition.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 Neuropsychological testing. Our reviewer says that there is no documentation justifying the need for Neuropsychological Testing therefore it is not considered medically necessary or reasonable. Our physician reviewer found the documentation does not show a worsening dementia based on therapy or utilizing the all steamy mental status exam or other testing devices. On review, the records provided in the information provided this member does not meet the criteria for neuropsychological testing as he previously had neuropsychological testing performed in 2017We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Neuropsychological testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Neuropsychological testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a wellness visit received on July 25, 2019.
You asked the Plan to pay for the services. You say that you were not told the purpose of this visit. The Plan denied your request. The Plan says this can only be done once a year.
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 annual wellness visits are covered once per year. The file shows that you received an annual wellness visit on March 4, 2019 and July 25, 2019. As they can only be covered once a year, the latter visit - the one at issue in this case - cannot be covered. Therefore, we decided that the Plan does not have to pay for a wellness visit received on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on October 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a specialist office visit. You say that this member came into your clinic. You say that you would like this service paid. The Plan denied your request. The Plan says no prior authorization was obtained 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 has network providers available who can provide 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 a specialist office visit provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74177).You asked the Plan to pre-approve the CT scan. You say that a CT scan is medically necessary.The Plan denied your request. The Plan says the enrollee has had no x-rays or ultrasound and that CT scan is not indicated at this time.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 the CT scan. Our reviewer says that coverage criteria have not been met. Our physician reviewer found the submitted medical records do not address the need for CT scan or contain an order for the CT Scan. Based on the submitted documentation, the CT scan is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the abdomen and pelvis (74177).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Xiidra eye drop solution.You asked the Plan to pre-approvethis medication. You say that this is the only eye drop solution effective in treating patients with dry eye syndrome.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.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-approvethe Xiidra eye drop solution.Benefits forthis medication may be available under Medicare Part D.Contactthe 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 pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on
January 28, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0648) provided to the enrollee on January 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids providedon July 30, 2018.You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says hearing aids must be ordered directly from hi HealthInnovations?.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 ordered directly fromhi HealthInnovations?.We looked at the fileand the Plan's rules. The file shows that the provider at issue in this case is not a Plan hearing aid 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 reimburse you for hearing aids providedon July 30, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services you received on September 25, 2019.
You asked the Plan to waive the copay for the services provided. You say that you should not have to pay for the mistakes that were made. The Plan denied your request. The Plan says the copay was applied based on 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 a $110 copay for each Medicare-covered emergency room visit. You have been asked to pay a $110 copay for the emergency room services provided. The services fall 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 copay for the emergency room services you received on September 25, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on October 4, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that the description suggests this was a greater service than it was. You say that this was part of your routine exam. 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 $325 per day for Medicare-covered diagnostic radiology services. You have been asked to pay $136.44, which is less than the standard $325 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 ultrasound provided on October 4, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for crisis intervention mental health services (HCPCS S9485) provided to the enrollee from September 24, 2019 to October 4, 2019.
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 this code is not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code S9485 is "Crisis intervention mental health services, per diem." We find that HCPCS code S9485 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 crisis intervention mental health services (HCPCS S9485) provided to the enrollee from September 24, 2019 to October 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on September 16, 2019.You asked the Plan to waive the copayment for emergency room visit. You say that your doctor was unavailable and the nurse told you to go to the emergency room or urgent care center.The Plan denied your request. The Plan says since an emergency room visit was provided, the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for emergency room visit. An emergency room 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 an emergency room visit provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says the service requested is 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator (E1390) provided on August 24, 2019, September 24, 2019 and October 24, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you received an oxygen machine in August and the provider never showed you how to use the machine until November. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC 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). Review of the records show you had the oxygen concentrator on August 24, 2019, September 24, 2019 and October 24, 2019. The provider did confirm that a technician went to your home on August 24, 2019 and provided lessons to your husband on how to use the machine and at the time your husband did sign the confirmation form authorizing that he was taught how the machine works. Therefore, the copayment applies to each date of service per your 2019 EOC. You are asked to pay 10% coinsurance for each date of service for the DME. 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 oxygen concentrator (E1390) provided on August 24, 2019, September 24, 2019 and October 24, 2019.