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

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from January 26, 2021, to February 23, 2021.

You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you were not informed that your benefits changed until after the second injection was received. You request that for this reason the Plan waive the cost-sharing 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 20% coinsurance for Medicare Part B prescription drugs. 

You received Medicare Part B drugs on January 26, 2021. The total allowed amount is $3,429.44 and 20% of that is $685.89. 

You received Medicare Part B drugs on February 23, 2021. The total allowed amount is $3,429.44 and 20% of that is $685.89. 

The total amount you owe is: $1,371.78.

You have been asked to pay the total coinsurance amount of $1,371.78 for Medicare Part B drugs. Medicare Part B drugs fall 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 Medicare Part B drugs provided from January 26, 2021, to February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided April 19, 2021.
You asked the Plan to pay for the orthosis. You say that this enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address Coronavirus concerns. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
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 thoracic-lumbar-sacral orthosis (L0457) provided April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transthoracic echocardiography (93306) provided April 2, 2021.

You asked the Plan to waive the copayment for the diagnostic service. You say that you do not feel you should be responsible for this copay because you did not choose the outpatient hospital setting. The Plan denied your request. The Plan says this claim was processed with the correct copayment applied per the Evidence of Coverage.

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 $125 copay for diagnostic procedures and tests at an outpatient hospital setting. 

You have been asked to pay $125 copay for the diagnostic service. The diagnostic service 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 transthoracic echocardiography (93306) provided April 2, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services (87635) provided on July 30, 2020. 
 
You asked the Plan to pay for the services. You say that the Plan denied your request. The Plan says that this is 
not a payable code. 
 
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 87635 is supported in the medical record. Specifically, the Plan's denial rationale is not 
valid in this case. A status indicator of "X" only denotes that the code is not payable on the Physician Fee 
Schedule, and does not imply that it is not payable by another Medicare payment system. As this is a laboratory 
test, it is payable under the Clinical Laboratory Fee Schedule, and Medicare has published specific pricing for 
this code. Based on this information, we decided that Medicare rules for coverage of the services have been 
met. Therefore, we decided that the Plan has to pay for the lab services (87635) provided on July 30, 2020.  
 
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the scooter provided on December 23, 2020.
You asked the Plan to pay for the scooter. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that an itemized bill was not provided.
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. In this case, the Plan denied payment for the scooter with the only denial reason of not receiving an itemized bill. However, the case file clearly has an itemized bill and you also sent an additional copy of the itemized bill to us and the Plan according to your additional information. We find that the Plan has not substantiated their reasoning for denial based on Medicare guidelines. Therefore, we decided that the Plan has to pay for the scooter provided on December 23, 2020.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the patient would benefit from going to a skilled nursing facility before being discharged home. The Plan denied your request. The Plan says that the patient would be equally well served at an alternative level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea (J0178), every 4 weeks for 1 year.
You asked the Plan to pre-approve Eylea. You say that the preferred drug is on back order through their preferred pharmacy. You also say that this is medically necessary. The Plan denied your request. The Plan says there is no documented clinical evidence of failure of trial of Avastin for the treatment of Macular Edema due to Retinal Vein Occlusion.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Eylea. Our reviewer says that Eylea is not medically necessary. Our physician reviewer found the medical records provided do not indicate that the enrollee has tried and failed the required drug, Avastin. The reviewer also found that there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Specifically, the record does not indicate that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Eylea (J0178), every 4 weeks for 1 year.
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 enrollee is having respiratory failure and is on a ventilator. You say that the enrollee's health is fading due to medical complications and that LTACH care is appropriate. The Plan denied your request. The Plan says the requirements for coverage of LTACH care have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with congestive heart failure and required intubation. The enrollee has had a stroke while an in-patient. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 records provided support the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the current clinical records show that the enrollee's needs can safely be met in the current hospital 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 is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response without transport provided on March 24, 2021.
You asked the Plan to pay for the ambulance response without transport. You say that you feel that this should be covered even if you did not go to the hospital. The Plan denied your request. The Plan says ambulance services are only covered when transport is provided.
The Plan follows Medicare rules. Medicare rules say that ambulance services are only covered when the enrollee is transported. The COVID waiver allows for coverage of ambulance response without transport only in instances where transport would have been reasonable but did not occur due to COVID EMS protocols. 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 ambulance response without transport. Our reviewer says that the services at issue do not meet the coverage criteria in this case. Our physician reviewer found the patient is a male with diabetes, on insulin, who had a low blood sugar and his father called the ambulance and gave him a tube of glucose. On arrival, EMS found the patient to have a normal glucose (65, 73, 81) and doing much better. Vitals were normal. Ambulance transport was refused by the patient as he was doing well. Based on the documentation provided, the ambulance services do not meet the CMS "treat in place" COVID-19 protocols for medically necessary ambulance services in this case. 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 ambulance response without transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance response without transport provided on March 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says SNF services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had uncomplicated
wound care to his sacrum and buttocks. He self-catheterized his bladder. The enrollee had no pain. Regarding
rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF.
By the dates in question, the enrollee was independent with transfers, activities of daily living and wheelchair
mobility. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical
matter, the enrollee 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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5261), hearing services (V5299), and sales tax (S9999) received on March 11, 2020.
You asked the Plan to pay for hearing aids, hearing services, and sales tax. You say that you want the Plan to reimburse you. The Plan denied your request. The Plan says the items were received from a non-participating provider and are not covered.
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 the Plan's hearing vendor is utilized. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids, hearing services, and sales tax have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5261), hearing services (V5299), and sales tax (S9999) received on March 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on March 2, 2021.
You asked the Plan to pay for the ambulance transport. You say that you feel that this trip should be covered as the enrollee needed to have her condition treated. The Plan denied your request. The Plan says this was not a medically necessary transport.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance transport. Our reviewer says that the ambulance transportation at issue was not shown to be medically reasonable and necessary. Our physician reviewer found the patient is a 78-year-old female who was experiencing trouble with her tracheostomy and EMS were called to transport her to a local pulmonologist to get help. On arrival, the patient's vitals were stable, she was in no distress, and physical findings were essentially normal or at baseline. Tracheostomy was capped without oxygen being administered with normal pulse oxygen saturation. Airway was cleared during transport when she appeared more comfortable. Trip was without incident. Based on the patient being assessed as hemodynamically stable without hypoxia or other acute issue requiring immediate treatment, stretcher van would not have been contraindicated here. The documentation did not show that the patient required expertise or special equipment during transport. Therefore, this request for ambulance transportation on 3/2/21 will be considered not medically necessary based on the documentation provided. 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 ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
You asked the Plan to pre-approve a pneumatic compression device. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Ogivri.
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 that the step therapy requirement is not met.
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 states that the step therapy requirement is not met; however, no medical records were received with the case file. Without medical records, a determination based on step therapy cannot be supported, as there is no documentation to support that the Plan's required drugs would not be contraindicated or less effective for the enrollee. Therefore, we decided that the Plan has to pre-approve Ogivri.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Topiramate 25 mg tablet.
You asked the Plan to pre-approve Topiramate tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Topiramate 25 mg tablet.
Benefits for Topiramate tablet may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.