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

We decided that the Plan does not have to pay for the ambulance services provided on November 7, 2019.
You asked the Plan to pay for the ambulance services. You say that after treatment you felt better and didn't see why you should get to the hospital. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 7, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the postoperative surgery provided on August 30, 2019.You asked the Plan to waive the copayment for the postoperative surgery. You say that you had to have a second surgery. You say that you should not have to pay.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for each Medicare covered hospital facility visit.You have been asked to pay a $295 copayment for the postoperative surgery. The postoperative surgery 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 for the postoperative surgery provided on August 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional home health skilled nursing visits.You asked the Plan to pre-approveadditional visits. The Plan denied your request. The Plan says the enrollee is not homebound.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 additional visits. Our physician reviewer found that the enrollee has a relevant past medical history that includes diabetes, heart disease, chronic kidney disease, endocrine disease, and alcohol abuse with a history of noncompliance. He was seen on March 31, 2020, and was ambulating back from the store on arrival. He was alert and oriented with clear speech and stable vital signs. He was in no acute distress. There were no changes to his medications and no reported recent falls. Leaving the home for nonmedical reasons does not support that he remains homebound.For these reasons,ongoing home-based skilled nursing care 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 additional visits have not been met.Therefore, we decided that the Plan does not have to pre-approveadditional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/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 an office visit provided on May 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493 and 64494).
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried physical therapy.
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 facet joint injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of physical therapy being attempted. There is also no documentation of the effectiveness of the right lumbar diagnostic medial branch blocks. In the absence of this information, the request cannot be considered medically reasonable or necessary 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493 and 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient clinic visits provided from July 30, 2019 to August 20, 2019.
You asked the Plan to waive the deductible for the outpatient clinic visits. You say that you were told the provider was in-network and you would have a $40 copayment per visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies toward out-of-network outpatient clinic visits.
The outpatient clinic visits you asked the Plan to waive the deductible for falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards out-of-network outpatient clinic visits. This cost sharing is a contractual obligation that had not been met at the time the outpatient clinic visits was received on July 30, 2019 to August 20, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient clinic visits provided from July 30, 2019 to August 20, 2019.
Your complaint about receiving misleading information is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services beginning March 23, 2020 for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 12, 2020 with paranoid schizophrenia. Based on the submitted records, it is not expected that she would improve in a reasonable period of time for the dates in question, as she does not have suicidal or homicidal ideation. She has decreased auditory hallucinations but no visual hallucinations. She is not showing dangerousness to self or others and is compliant with treatment. It does not appear that active treatment is taking place beyond the date in question. The continued inpatient services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services beginning March 23, 2020 for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
The enrollee asked the Plan to pay for the ambulance services. The enrollee said that he was on vacation when his blood sugar got too low and he passed out. The enrollee's family called 911 and the responders revived the enrollee. The enrollee said he was okay and needed no further assistance. The Plan denied the enrollee's request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan or derivative, Gel-one, for intra-articular injections.
You asked the Plan to pre-approve the Gel-one. You say that arthritis caused your meniscus to tear. You also say that you would like to use the Gel-One instead of a steroid to help ease the pain. The Plan denied your request. The Plan says there is no record of you having tried a steroid injection of your knees, which is required per your policy. The Plan also says that you need to have tried an injection with either Synvisc or Euflexxa prior to using the medicine Gel-one.
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 the Gel-one. Our reviewer says that the criteria coverage has not been met. Our physician reviewer found the provided medical records do not indicate that you have tried and failed the required drugs, either Synvisc or Euflexxa. Our reviewer also found that the provided medical records do not indicate that the Plan's required drugs, Synvisc or Euflexxa, would likely be less effective and/or likely have adverse effects for you.
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 Gel-one have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative, Gel-one, for intra-articular injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hemoglobin testing machine.
You asked the Plan to pre-approve the machine. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered machine.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the machine. Our reviewer says that the requested machine is not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the request for a hemoglobin testing machine is denied as a hemoglobin testing machine is not a Medicare covered benefit. This is not the standard of care as it is only a convenience for you. In addition there is no way of knowing how accurate the measurements are. The review has determined that the requested hemoglobin testing machine should not be considered medically necessary DME. 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 machine have not been met. Therefore, we decided that the Plan does not have to pre-approve a hemoglobin testing machine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided on October 24, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service is included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress.You asked the Plan to pre-approvethe requested mattress. You say that the mattress will keep the enrollee from applying so much pressure.The Plan denied your request. The Plan says the records do not show the enrollee has wounds, ulcers, or skin grafts.The Plan follows Medicare rules. Medicare rules say that pressure reducing support surfaces are only covered under certain medical indications.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 requested mattress. Our physician reviewer found that the enrollee does not have multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the enrolleehas been on a comprehensive ulcer treatment program. There is no evidence oflarge or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis,a myocutaneous flap,or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. There is no evidence the enrolleehas been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days. Therefore, the requested item is not medically reasonable or necessary.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on January 7, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you have never been charged in the past and disagree with the 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 a Medicare Part B drug on January 7, 2019. The allowed amount is $1,116.66 and 20% of that is $223.33. You have been asked to pay the total coinsurance amount of $223.33 for a Medicare Part B drug. A Medicare Part B drug falls 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 a Medicare Part B drug provided on January 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not 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 based on the documentation provided, the enrollee is currently undergoing treatment following conversion of a below the knee amputation. The enrollee has a tracheotomy, ventilator and feeding tube at baseline. There is no evidence that the enrollee requires services that are not currently available in the current facility. As acute care hospitals and long-term acute care hospitals are licensed to provide the same level ofcare, there is no advantage in transferring the enrollee from the current facility. Medicare coverage criteria for transfer to an LTACH are not met.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 for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 24, 2019 through October 31, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because S9328 is a valid code. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and 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 CPT code. We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 24, 2019 through October 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on January 13, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that you believe checking your iron levels is a preventive service because if you become deficient you will end up in the hospital. You say this has always been covered before. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $10 copayment for the laboratory work. The laboratory work 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 laboratory work provided on January 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4Kscore testing.
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 the testing is not covered.
The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare. We looked at the file and Medicare rules. The requested services are 4Kscore testing. This testing is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve 4Kscore testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ileostomy supplies to be provided by the out of network provider.
You asked the Plan to pre-approve the ileostomy supplies from an out-of-network supplier. You say that you prefer this supplier because the in-network supplier refuses to provide the accessories you require. The Plan denied your request. The Plan says all your requested supplies are approved with an in-network supplier.
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 at issue in this appeal. We found no exception that would require the Plan to pre-approve these items from an out-of-network supplier. Therefore, we decided that the Plan does not have to pre-approve the ileostomy supplies to be provided by out of network provider.