Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance the infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222) Injection, rituximab, 10 mg (J9312) provided October 7, 2020 to October 21, 2020.
You asked the Plan to waive the coinsurance the infusion services. You say that it was confirmed that there was an authorization in place, and you were under the impression that it would be fully covered with the authorization. The Plan denied your request. The Plan says the claim was processed, and the correct cost share was 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 15% of the total cost for Medicare covered Part B prescription drugs, including chemotherapy drugs. You have been asked to pay $2,137.42 for the infusion services. The infusion services 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 the infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately) (A4222) Injection, rituximab, 10 mg (J9312) provided October 7, 2020 to October 21, 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 this is medically necessary. The Plan denied your request. The Plan says medical needs can be met a lower level.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 and non-surgical management of a humerus 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, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room (ER) services rendered on September 13, 2020.You asked the Plan to waive the copayment forthese services. You say that the services did not resolve your issue.The Plan denied your request. The Plan says the copayment was 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 $110 copayment for each covered ER visit. Review of the file shows that you received ER services on September 13, 2020. You have been asked to pay a $110 copayment for these services. These services fall within the covered ER 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 forthe emergency room (ER) services rendered on September 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on November 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says there are in-network providers available 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 had network providers available who could have provided 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 dermatology services provided on November 5, 2020 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 from November 30, 2020, to December 8, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee had to be readmitted to the hospital and you are not sure if they should be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment for days 1-5 for inpatient hospital care. The medical records show that the enrollee had an inpatient hospital stay from November 30, 2020, to December 8, 2020. Therefore, they are responsible to pay a $225 copayment for days 1-5 (November 30, 2020, to December 4, 2020). $225 (copayment) x 5 (inpatient days) = $1,125. The enrollee has been asked to pay the total copayment amount of $1,125 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from November 30, 2020, to December 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe brief emotional/behavioral assessment and domiciliary or rest home visit provided on December 2, 2020 by an OON provider.You asked the Plan to pay forthe brief emotional/behavioral assessment and domiciliary or rest home visit. You say that the services provided were medically necessary.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that prior 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 had network providers available who could have provided 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 forthe brief emotional/behavioral assessment and domiciliary or rest home visit provided on December 2, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided from November 24, 2020 to December 7, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received inpatient rehabilitation services on the dates of service at issue in this appeal. The Plan says that the correct copayment 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 $250 copayment per day for days 1-7 for Inpatient hospital care. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received inpatient rehabilitation services from November 24, 2020 to December 7, 2020. You have been asked to pay a $250 copayment per day for days 1-7 for the inpatient rehabilitation services, totaling $1750. The inpatient rehabilitation services fall 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 the inpatient rehabilitation services provided from November 24, 2020 to December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 8, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physician services rendered on September 14, 2020.
You asked the Plan to waive the copayment for these services. You say that you were only seen for a wellness visit. The Plan denied your request. The Plan says the copayment was 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 $10 copayment for each covered visit or consultation in an outpatient location with your primary care physician (PCP) or other primary care provider.
Review of the file shows that you received services with your PCP on September 14, 2020. These services were performed to evaluate your condition of high blood pressure (hypertension). You have been asked to pay a $10 copayment for these services. These services fall within the covered visit or consultation in an outpatient location with your primary care physician (PCP) or other primary care provider 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 physician services rendered on September 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. You say that the requested spinal cord stimulator is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested spinal cord stimulator.
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 a spinal cord stimulator. Our reviewer says that the enrollee does not meet criteria for the requested spinal cord stimulator. Our physician reviewer found the enrollee has chronic low back pain. She only takes Tylenol for pain. She has had physical therapy and "spinal injections" without sustained pain relief. She had a psychological evaluation which cleared her for a SCS trial. She has not had prior spine surgery and does not have an evidence-based indication for a SCS trial. She has not had any topical or intra-thecal medication trials. The enrollee does not have an indication for a SCS trial and has other modalities available to treat her pain. The request is not medically reasonable or 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the enrollee did undergo surgery and required the use of this device. You feel that you should be compensated for the services provided to the enrollee during surgery for their safety and well-being. The Plan denied your request. The Plan says a pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. This equipment was used in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery.
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 pay for a pneumatic compression device (E0676).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient hospital care provided from April 6, 2020, through April 12, 2020.You asked the Plan topay forthe inpatient hospital care. The Plan denied your request. The Plan says Original Medicare would be responsible for paymentof all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit,through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge orrevocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated tothe terminalillness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on April 6, 2020. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay forinpatient hospital care provided from April 6, 2020, through April 12, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forZB8N7 genetic testing provided on November 12, 2020.You asked the Plan to pay forgenetic testing.You say that this testing is covered by Medicare.The Plan denied your request. The Plan says the denial of payment for this test is correct, because this test was not ordered or approved by the ordering physician.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab service denied by the Plan on this claim. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forZB8N7 genetic testing provided on November 12, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on January 6, 2021.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. Routine eye refractions are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on January 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on December 15, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on December 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you have used 14 of the allotted one-way trips for the 2021 benefit year and have 10 one-way trips remaining. The Plan says that additional routine trips will not be approved.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year. We looked at the file, the Plan's contract and Medicare rules. The file shows that you have used 14 of the allotted 24 one-way trips for the 2021 benefit year. You have 10 trips remaining and then you will have exhausted your transportation benefit for the calendar year. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cardiovascular risk assessment panel provided on September 9, 2020.You asked the Plan to pay forthe cardiovascular risk assessment panel. The Plan denied your request. The Plan says that this is not a covered service.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 payfor the cardiovascular risk assessment panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has no specific indications for the gene varianttesting noted. If she has established cardiovascular disease, cardiomyopathy or clinical risk factors for this (hypertension, hyperlipidemia, etc.) she should be appropriately treated with lifestyle modification and medical therapy, as indicated, based onher assessed clinical risk or the presence of active clinical disease. There are no reasonable medical indications noted for referral for gene variant panel testing.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 cardiovascular risk assessment panel have not been met. Please note that the LCD referenced by the Plan in its determination is not applicable for the jurisdiction in question.Therefore, we decided that the Plan does not have to pay forthe cardiovascular risk assessment panel provided on September 9, 2020.