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

We decided that the Plan has to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not a covered benefit.
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 has not provided any medical records. The requested provider is a contract provider, so the plan should be able to get these records. Therefore, we decided that the Plan has to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from September 15, 2018 through September 18, 2018.
You asked the Plan to pay for post-stabilization care. You say that the claim should be paid. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 post-stabilization care. Our physician reviewer found the review has determined that the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring and oxygen to a Plan facility for observation/admission level of care services after the emergency room evaluation on September 15, 2018. There was no documentation provided necessitating post-stabilization care services September 15, 2018 through September 18, 2018 at the non-participating Plan facility. The post-stabilization care services were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post-stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post-stabilization care provided to the enrollee from September 15, 2018 through September 18, 2018.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says that current needs can be managed at a lower level of care such as home health.
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 did not substantiate their denial. No medical records were provided by the plan. The case file indicates that records were available for the plan's original review. Therefore, we decided that the Plan has to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction provided on January 28, 2020.
You asked the Plan to pay for the extraction. You say that you and your dentist contacted the Plan and verified that you had comprehensive coverage. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you are not enrolled in the optional benefit that covers comprehensive dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction provided on January 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses and shoulder orthosis provided on
December 9, 2019.
You asked the Plan to pay for the ankle foot orthoses (L1906) and shoulder orthosis (L3670). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses were not
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the ankle foot orthoses (L1906) and shoulder
orthosis (L3670). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer
found the enrollee's chief complaints were chronic pain located in the Ankle Left, Ankle Right, and Shoulder
Right, documented in 2 separate notes on the same date of service.
The documentation in the case file does not support that the requested ankle/foot orthoses were medically
reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A
physical examination of the ankles and feet would reasonably be required to adequately assess whether the
coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically
reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination
of the ankles and feet.
The documentation in the case file does not support that the requested shoulder/arm orthosis was medically
reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably
be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee.
The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee
in this case, as there is insufficient documentation of a credible physical examination of the shoulder.
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 ankle foot orthoses (L1906) and shoulder orthosis (L3670) have not been
met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses and shoulder orthosis
provided on December 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $350 copayment charged for ambulance transport
provided on June 11, 2019.
You asked the Plan to waive this copayment. You say that this copayment is outrageous. The Plan denied your
request. The Plan says this copayment is listed in your Plan contract agreement.
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 $350 for
ambulance transport.
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 $350 copayment charged for ambulance transport provided on June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on
November 21, 2019.
You asked the Plan to pay for the knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the
orthoses were medically necessary. The Plan denied your request. The Plan says the orthoses were not
medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the knee orthosis (L1833LT) and suspension
sleeve (L2397LT). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer
found the enrollee's chief complaint was left knee pain. The documentation in the case file does not support that
the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case,
according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or
recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of
joint laxity.
The item coded L2397 (sleeve) is not separately payable when the base item is not covered.
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 knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been
met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve
provided on November 21, 2019.
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 if the enrollee requires ongoing acute level care, the enrollee should remain in the current setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy may be more appropriate. It is not clear that you would be able to fully benefit from and/or participate in an IRF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve the chiropractic services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested provider is out of network; there are available providers within the network that can render the requested 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be rendered by the out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from February 1, 2020 through February 3, 2020 and February 25, 2020 through February 26, 2020.
You asked the Plan to waive the copayment for the observation stays. You say that you were admitted in both cases. You say that error should be corrected. The Plan denied your request. The Plan says the copayments 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 $350 copayment per stay for outpatient observation stays. You have been asked to pay a $350 copayment for each observation stay. The total amount you owe is $700 ($350/stay x 2 stays = $700). The observation stays fall within the "Outpatient Hospital Observation" benefit category. The records show that you were admitted to outpatient observation. 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 observation stay provided from February 1, 2020 through February 3, 2020 and February 25, 2020 through February 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for observation or inpatient hospital care. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit. (99236) provided to the enrollee on January 16, 2020 .
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The billed observation care service, 99236, was denied because another observation service was reported for the same date of service. Therefore, we decided that the Plan does not have to pay for observation or inpatient hospital care. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit. (99236) provided to the enrollee on January 16, 2020 .
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (A6549).
You asked the Plan to pre-approve the compression stockings. You say that compression stockings are medically necessary to reduce the swelling in the enrollee's lower legs. The Plan denied your request. The Plan says compression stockings are not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate for the enrollee, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings (A6549).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccine provided on February 12, 2020.
You asked the Plan to pay for vaccines under Medicare Part B. You say that this claim should be paid. The
Plan denied your request. The Plan says preventative vaccines are not covered under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide vaccines under
Medicare Part B. The Plan follows the same rules. The records do not show that you have been injured or
directly exposed to any illness related to vaccines under Medicare Part B. Therefore, we decided that the Plan
does not have to pay for a vaccine provided on February 12, 2020.
Benefits for vaccines may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $125 copayment charged for ambulance transport on
January 30, 2020.
You asked the Plan to waive this copayment. You say that you were transferred from one hospital to another
and they would not let your husband drive you. You do not believe you should have to pay this copayment. The
Plan denied your request. The Plan says this copayment was charged based on the transport provided and the
Plan contract agreement.
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
copayment for ambulance transport.
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 $125 copayment charged for ambulance transport on January 30, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that the requested Synvisc is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Orthovisc and Monovisc first.
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 Synvisc. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee has a diagnosis of Bilateral primary osteoarthritis of the knees. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Synvisc. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha 140 mg/ml SureClick for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha 140 mg/ml
SureClick for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for gait training (97116) provided on July 8, 2019.
You asked the Plan to pay for gait training. You say that you did walking training on your own at the end of your session. The Plan denied your request. The Plan says this service is not documented in the record.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 97116 is therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing). We find that CPT code 97116 is not supported in the medical record. Specifically, gait training is not documented in the submitted medical records as having been performed by the physician. Based on this information, we decided that Medicare rules for coverage of gait training have not been met. Therefore, we decided that the Plan does not have to pay for gait training (97116) provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen (J0885).
You asked the Plan to pre-approve the Epogen. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Epogen. Our reviewer says that the provided medical records do not indicate that the member has tried and failed Retacrit. Our physician reviewer found the provided medical records do not indicate that the Plan's required drug would likely be less effective. 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 Epogen have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen (J0885).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax for the items provided on August 30, 2019.
You asked the Plan to pay for the sales tax. You say that the Plan should pay for the expenses. The Plan denied your request. The Plan says they will pay the Medicare allowed rate of the items but sales tax is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales tax. We looked at the file and Medicare rules. Sales tax is not separately payable. Therefore, we decided that the Plan does not have to pay for the sales tax for the items provided on August 30, 2019.