Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for fitness equipment purchased on August 30, 2020.
You asked the Plan to pay for fitness equipment. You say that you called the Plan prior to purchasing the equipment and was told you would be reimbursed. You also say that you received information from the Plan stating this would be covered. The Plan denied your request. The Plan says the fitness equipment was purchased before October 1, 2020, is not eligible for reimbursement under the Plan's health and wellness benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits only The Plan contract for 2020 states that the Plan can pay up to $150 per calendar year toward your cost of a membership in a qualified health club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this benefit may also be used toward the purchase of exercise equipment that you can use at home. Purchases made prior to October 1, 2020, do not qualify. The Plan's rules for coverage of gym benefits have not been met because this purchase was made prior to the Plan's policy changes that became effective on October 1, 2020. Therefore, we decided that the Plan does not have to pay for fitness equipment purchased on August 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy dose plan provided on April 10, 2020.
You asked the Plan to waive the coinsurance for the radiation therapy dose plan. You say that if the claim was submitted earlier you would not owe this amount because you met your deductible by the end of May 2020. The Plan denied your request. The Plan says the claim was originally submitted on April 28, 2020 and your maximum out of pocket was not reached until May 15, 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 20% coinsurance for Outpatient Therapeutic Radiology Services.
You have been asked to pay 20% coinsurance for the radiation therapy dose plan. The radiation therapy dose plan falls within the Outpatient Therapeutic 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. The original claim was submitted before you had reached your MOOP. The provider submitted a corrected claim, but it does not change the original coinsurance due. Therefore, we decided that the Plan does not have to waive the coinsurance for the radiation therapy dose plan provided on April 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve photochromatic lens tint (V2744).
You asked the Plan to approve photochromatic lens tint. You say that you would like reconsideration for the transition lenses. The Plan denied your request. The Plan says this service is not covered by the Plan benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan does not cover this service. We looked at the file and the Plan's rules. The service at issue is not a covered benefit of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of photochromatic lens tint have not been met. Therefore, we decided that the Plan does not have to approve photochromatic lens tint (V2744).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on March 2, 2021 or waive the copayment for the ambulance services provided on March 11, 2021.
You asked the Plan to pay for the ambulance services provided on March 2, 2021 and waive the copayment for the ambulance services provided on March 11, 2021. You say that you would like reconsideration because you were taken to the hospital against your will and should not have to pay. The Plan denied your request. The Plan
says you are responsible for $290.00 for ambulance services and Medicare will only make payment when there is actual transportation of the beneficiary.
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 $290 copayment for the ambulance services. The item or service you asked the Plan to pay for falls within the ambulance services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 copayment for Ambulance Services. 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. The rules also say that if an ambulance responds to a call but does not transport the person for whom the call was placed, Medicare does not pay for the service. Based on the documentation submitted, we have determined that Medicare coverage criteria for the ambulance services provided on March 11, 2021 have not been met. Specifically, the record indicates that the ambulance responded to a call, but you refused transport to the emergency room. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on March 2, 2021 or waive the copayment for the ambulance services provided on March 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from April 16, 2021, to April 18, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that these services were medically necessary and should be covered in full. The Plan denied your request. The Plan says these services were covered and processed correctly. You owe a $780 copayment for the inpatient care.
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 $390 copayment for each of the first 5 days of an inpatient hospital stay. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor's order. The day before you are discharged is your last inpatient day. You have been asked to pay a $780 copayment for the inpatient hospital care. You were admitted on April 16, 2021, and discharged on April 18, 2021. There are two days which are billable for your inpatient services. Each day requires a $390 copayment ($390 x 2 days = $780). 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 hospital admission and services provided from April 16, 2021, to April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a second anterior segment aqueous drainage device.
You asked the Plan to pre-approve insertion of a second anterior segment aqueous drainage device. 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 follows Medicare rules. Medicare rules say that in summary, Palmetto GBA considers one iStent, iStent inject (device capable of delivering two individual iStents per eye), medically reasonable and necessary for the treatment of adults with mild or moderate open-angle glaucoma and a cataract when the individual is currently being treated with an ocular hypotensive medication and the procedure is being performed in conjunction with cataract surgery. 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 insertion of a second anterior segment aqueous drainage device. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the record indicates that the enrollee has glaucoma and is undergoing cataract surgery. The plan has approved the insertion of a 0191T device. The requested 0376T request is a second device insertion and excluded by the criteria of the local coverage determination. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a second anterior segment aqueous drainage device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a second anterior segment aqueous drainage device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on January 22, 2021.
You asked the Plan to pay for the paramedic intercept services. You say that you were dizzy and had difficulty walking. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on January 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), sphere lenses (V2100) and a miscellaneous vision item (V2799) provided on January 22, 2021.
You asked the Plan to pay for eyeglass frames, sphere lenses and a miscellaneous item. You say that you have provided an itemized list of services and eyewear for reconsideration of payment. The Plan denied your request. The Plan says you are responsible for additional payments above the $200 allowed benefit. The Plan also says that you received a second set of lenses in March and the claim was paid prior to receiving your itemized receipt from January.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you pay $0 for eyeglass frames every 24 months when you use a network provider. If you choose eyeglass frames priced above $200, you are responsible for the difference. The Plan contract also says you pay $0 for either one pair of eyeglass lenses or for contact lenses priced up to $400, every 12 months. We looked at the file and the Plan's rules. The $200 allowance only applies to frames and lenses. The records show that the frames you purchased were $650. The Plan reimbursed you the allowed amount of $200 for the frames purchased which left you with a $450 balance. The balance on the frames is your responsibility. The records also show that you ordered a second set of lenses on March 12, 2021 and the claim was paid before your itemized receipt from January 22, 2021 was received. You are allowed one set of lenses every 12 months, therefore, the sphere lenses on this claim are not covered. The records also show that miscellaneous vision items are not covered by the Plan benefit. Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, sphere lenses and miscellaneous item have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), sphere lenses (V2100) and a miscellaneous vision item (V2799) provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on an out-of-network provider on March 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the services provided on an out-of-network provider on March 19, 2021.
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 the enrollee in this case requires services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for a bone marrow biopsy provided on March 15, 2021.

You asked the Plan to reduce the copayment for a bone marrow biopsy. You say that this is the closest and most convenient facility near your home, and you would like the copayment to be $275. 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 $440 copayment for non-preferred outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

The record shows that you received a bone marrow biopsy at a non-preferred outpatient hospital facility on March 15, 2021. Therefore, you are responsible to pay the $440 copayment. 

You have been asked to pay a $275 copayment for a bone marrow biopsy. A bone marrow biopsy falls within the non-preferred 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 reduce the copayment for a bone marrow biopsy provided on March 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services to be provided by an out-ofnetwork
(OON) provider.

You asked the Plan to pre-approve home health services to be provided by an OON provider. You say that the
services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able
to provide these services. Therefore, coverage criteria have not been met.

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
home health services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis (L1845) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the supporting documentation submitted by the provider notes that the knee is stable.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has arthritis of the knee. The physical examination does not document instability demonstrated by provocative testing. The record does not indicate that the enrollee has had a recent injury or surgery upon the knee in question. The elements of the coverage criteria are not satisfied. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis (L1845) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gingival flap procedure.

You asked the Plan to pre-approve a gingival flap procedure. You say that the service is necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit.

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 pre-approve a gingival flap procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided January 16, 2021.

You asked the Plan to waive the copayment for the non-emergency transport and ground mileage. You say that the enrollee is allowed 6 transportation trips. The transportation was arranged by the Plan's transportation vendor who told you the services should be covered. The Plan denied your request. The Plan says this service does not qualify as routine transportation. The non-emergency ambulance copayment has been 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $25 copayment per one-way trip (includes ground and air transport) for each Medicare-covered
ambulance service. Routine non-emergent transportation services are covered up to six one-way trips per
calendar year to in-network medical appointments or visits to providers within the plan service area.

The enrollee has been asked to pay a $225 copayment for the non-emergency transport and ground mileage.
This service falls within the Ambulance services benefit category. The routine transportation benefit is
designated for trips to in medical appointments and providers within the plan service area. The non-emergency
transport in this case was provided as a result of a discharge from the hospital. 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 the ambulance service, basic life support, non-emergency transport (A0428)
and ground mileage (A0425) provided January 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that this scooter will improve activities of daily living.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found you do not have a personal mobility deficit that significantly impairs participation in MRADLs. You do not have the space in your home to safely maneuver the requested device. 

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve an electric scooter.