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

We decided that the Plan does not have to pre-approve the prosthesis additions as defined by codes (L5981, L5968, L5910).
You asked the Plan to pre-approve the prosthesis additions. You say that these parts are necessary. The Plan denied your request. The Plan says while they have overturned the other parts of the prosthesis and additions, the prosthesis additions as defined by codes (L5981, L5968, L5910) remain denied.
The Plan must follow Medicare rules. Medicare rules say that it will cover services that meet but not exceed the enrollee's needs. The preparatory prosthesis (L5540) has been approved. The full description for L5540 indicates that this is a non-alignable system. The code (L5910) is for an alignable system and cannot be used with this preparatory prosthesis. There is no documentation in the records provided to support functional level designated by the prosthetist. The requested K3 components (L5981, L5968) exceed the member's needs and cannot be covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the prosthesis additions have not been met. Therefore, we decided that the Plan does not have to pre-approve the prosthesis additions as defined by codes (L5981, L5968, L5910).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a
participating provider on November 16, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that this was supposed to be
covered 100%. The Plan denied your request. The Plan says 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 $35
copayment for physician/practitioner services/specialist visit.
You have been asked to pay a $35 copayment for a specialist office visit. A preventive screening service will
not have a copayment. However, if you are also treated or monitored for an existing medical condition during
the visit when you receive the preventive service, cost-sharing may apply. A specialist office visit falls within
the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider on November 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 surgical repair of a hip fracture after a fall and was discharged home with home health physical therapy on 3/20/21. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient psychiatric hospital services provided from March 27,
2020, to March 30, 2020.
You asked the Plan to pay for the inpatient psychiatric hospital services. The Plan denied your request. The
Plan says that the inpatient care is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric hospital services.
Our reviewer says that the requested psychiatric hospital services were medically reasonable and necessary in
this case. Our physician reviewer found that based on the records provided, the admission of this enrollee does
meet the coverage criteria for acute inpatient mental health treatment, as this enrollee was shown to be a danger
to himself, but not others. He was without agitation or aggression, but had perceptual disturbance including
auditory hallucinations.
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 inpatient psychiatric hospital services have been met. Therefore, we decided
that the Plan has to pay for the inpatient psychiatric hospital services provided from March 27, 2020, to March
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on August 6, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you feel that you should not owe a copayment due to your distress with the Plan. 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 $250 copayment for diagnostic radiology services. You have been asked to pay a $250 copayment for an MRI. An MRI 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 an MRI provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays for the office visits provided from August 21, 2020, to November 2, 2020.
You asked the Plan to waive the copays for the services provided. You say that you should not have to pay because your ostomy is still leaking. The Plan denied your request. The Plan says the copay processed 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 $10 copay for each covered visit in an outpatient location with a primary care provider. The file shows that you received services on August 21 and 30, 2020, September 14 and 28, 2020, October 19, 2020, and November 2, 2020. You have been asked to pay a $10 copay for the services provided on each date at issue. The services fall within the physician 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 copays for the office visits provided from August 21, 2020, to November 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery (63650, L8680) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON spinal surgery. You say that the enrollee needs this surgery. The Plan denied your request. The Plan says this 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 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 spinal surgery (63650, L8680) 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 waive the copayment for an inpatient hospital stay provided by a participating provider on July 23, 2020, to July 25, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you cannot afford this copayment. The Plan denied your request. The Plan says 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 $393 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient hospital care. You have been asked to pay a $393 copayment per day for days 1-2 for an inpatient hospital stay. The total amount you are being asked to pay is $786 ($393 x 2 days = $786). The correct copayment has been applied to the inpatient hospital stay that was provided. 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 provided by a participating provider on July 23, 2020, to July 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been
met.
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 pre-approve acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient admission. Our physician
reviewer found the arthroplasty procedure is currently approved as an ambulatory outpatient procedure. There
is no documentation provided to support the expectation that you will require a greater than 2 midnight stay.
The review has determined that the record does not show that inpatient admission is medically reasonable and
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 pre-approve acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay.

You asked the Plan to waive the copayment for a SNF stay. You say that you could have been discharged after
20 days and disagree with the additional charges. The Plan denied your request. The Plan says the claims were
processed correctly, and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20
copayment for days 1-20, and an $80 copayment for days 21-100 for SNF care.

You had a SNF stay. You are responsible to pay a $20 copayment for days 1-20. $20 (copayment) x 20 (SNF days) = $400. You are also responsible to pay an $80 for days 21-26. $80 (copayment) x 6 (SNF days) = $480. 
The total amount you owe is: $880.

You have been asked to pay the total copayment amount of $880 for a SNF stay. A SNF stay falls within the
SNF 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 a SNF stay.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set-up of a portable x-ray (Q0092 and
R0070) provided on July 31, 2020.
You asked the Plan to pay for the transportation and set-up of a portable x-ray. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare rule for
payment of this claim has not been met.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the
transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the transportation and set-up of a portable x-ray have not been met. Specifically, this claim was
billed with place of service code 31, indicating that the member was in a Part A SNF stay. The transportation
and set-up costs are not separately billable to Medicare Part B in this case. Therefore, we decided that the Plan
does not have to pay for the transportation and set-up of a portable x-ray (Q0092 and R0070) provided on July
31, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee in this case. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on April 8, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you cannot afford this total amount. The Plan denied your request. The Plan says 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 $250 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests/diagnostic radiology 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 copayment for a CT scan provided by a participating provider on April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 9, 2020.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. 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 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 domiciliary, rest home visit. 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 a domiciliary, rest home visit provided on December 9, 2020.
Appeal type: Drugs
Decision: Partially Favorable

We decided that the Plan has to lower the coinsurance for Rb82 rubidium and regadenoson. We decided that
the Plan does not have to waive the coinsurance for Rb82 rubidium (A9555) and regadenoson (J2785) provided
on April 11, 2020.
You asked the Plan to waive the coinsurance for Rb82 rubidium and regadenoson. You say that this was
calculated incorrectly. The Plan says that the coinsurance was correctly applied.
We decided that the Plan has to lower the coinsurance for Rb82 rubidium (A9555) and regadenoson
(J2785) provided on April 11, 2020.
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 enrollees must pay a 20% coinsurance for Medicare Part B drugs.
The Plan says you must pay $128 for Rb82 rubidium, 20.4% of the $629.76 allowed amount, and $43.20 for
regadenoson, 20.3% of the $212.54 allowed amount. Based on the Plan contract, however, you cannot be asked
to pay more than a 20% coinsurance for Medicare Part B drugs. Therefore, we decided that the Plan has to
lower the coinsurance for Rb82 rubidium (A9555) and regadenoson (J2785) provided on April 11, 2020.
We also decided that the Plan does not have to waive the coinsurance for Rb82 rubidium (A9555) and
regadenoson (J2785) provided on April 11, 2020.
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 drugs. The contract also says that supplies for which an appropriate separate
charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to
cost-sharing. Therefore, we decided that the Plan does not have to waive the coinsurance for Rb82 rubidium
(A9555) and regadenoson (J2785) provided on April 11, 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.