Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for enrollee.You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for respiratory failure due to viral infections. The enrollee was intubated/ventilated upon presentation. He subsequently received a tracheotomy, and as of February 17, 2020, remained on a ventilator. The documentation does not clearly show the extent or results of weaning. The documentation does not clearly note a long-term prognosis or treatment plan. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cochlear device implantation.You asked the Plan to pre-approve cochlear device implantation. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that cochlear implantation may be covered when specific criteria is met.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 cochlear device implantation. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had aided testing completed in the best aided condition for each ear. Aided responses were obtained at 92% in quiet and 63% in noise in the best aided condition. The enrollee suffers from single sided deafness, and therefore does not meet criteria for CI implantation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cochlear device implantation have not been met.Therefore, we decided that the Plan does not have to pre-approve cochlear device implantation
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe presumptive and definitive drug testing provided to the enrollee on May 4, 2019.You asked the Plan to pay forthe drug testing. The Plan denied your request. The Plan says the documentation did not include a lab order or records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that providers must produce medical records showing why the lab services provided were medically necessary.We looked at the file and Medicare rules. In this case, there were insufficient records that show the tests were needed to identify specific substances. There is no evidence that shows the testswereindividualized to identify specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement.Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plandoes not have to pay forthe presumptive and definitive drug testing provided to the enrollee on May 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve study provided on July 9, 2019.
You asked the Plan to waive the copayment for the nerve study. You say that you thought you were only responsible for the specialist copayment. You say you are on a limited income and cannot afford the copayment. 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 $300 copayment for all other diagnostic procedures and tests. You have been asked to pay a $300 copayment for the nerve study. The nerve study 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 nerve study provided on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 19, 2019 by an out of network (OON) provider.You asked the Plan to pay for the out-of-network labs. The Plan denied your request. The Plan says there is no network deficiency for the services provided.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 services at issue in this appeal. The Plan did not pre-approve the lab service at issue. We found no exception that would require the Plan to pay for these out-of-network services.Therefore, we decided that the Plan does not have to pay for the lab services provided on April 19, 2019 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe darbepoetin alfa injection on August 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim is not payable.The Plan must follow Medicare rules. The rules say that non-pass through drugs and biologicals (status indicator K) are not typically packaged under the OPPS.We looked at the file and Medicare rules. The provider submitted a claim for procedure code J0881 without any associated OPPS procedures. The claim is not payable as billed.Therefore, we decided that the Plan does nothave to pay forthe darbepoetin alfa injection on August 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 18, 2019 and September 21, 2019.
You asked the Plan to waive the copayment for laboratory services. You submitted your bills for review. 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 $30 copayment for in-network laboratory services. You have been asked to pay a $30 copayment for each visit for laboratory services. The total amount you owe is $60 ($30/visit x 2 visits = $60). Laboratory services fall 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 laboratory services provided on September 18, 2019 and September 21, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ER visit on June 3, 2019.You asked the Plan to waive the copayment foran ER visit. You say that the doctor did nothing for you,so you signed out.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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency 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 foran ER visit on June 3, 2019.We note your complaint that the doctor did nothing for you. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ED visit provided on November 7, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that you waited for seven hours. You say that all you had done was a blood draw.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 $90 copayment per visit for Medicare-covered emergency room visits.You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were examined, had blood drawn, an IV was inserted and a duplex scan was performed during the ED visit. 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 ED visit provided on November 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe power operated vehicle rental provided on July 8, 2019.You asked the Plan to reimburse you forthe power operated vehicle rental. You say that you had trouble finding an in-network supplier.The Plan denied your request. The Plan says the supplier is not a Medicare certified supplier.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or provider who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situationr. This provider has opted out of the Medicare program. The file shows that the supplier entered into a privatecontract with you regarding payment.Therefore, we decided that the Plan does not have to reimburse you forthe power operated vehicle rental provided by the supplier on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on September 16, 2019.You asked the Plan to waive the deductible for an office visit. You say that you were told by the office staff that the provider was in-network.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. Your contract with the Plan says that there is a combined deductible of $490 for in-and-out-of-network services.You had an office visit with an out-of-network provider on September 16, 2019. The record shows that you had only paid $37.65 toward the $490 combined deductible. Therefore, you are responsible to pay the allowed amount of $117.44. The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a combined deductible of $490 for out-of-network physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on September 16, 2019.Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on September 16, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity Injections, 0.75mg/0.5mg.
You asked the Plan to pre-approve Trulicity. You say that Trulicity is medically necessary. The Plan denied your request. The Plan says coverage for Trulicity is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Trulicity Injections, 0.75mg/0.5mg.
Benefits for Trulicity 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the 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 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do not require this or appear to be able to tolerate this therapy on an intensive rehabilitation facility therapy program level 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the seed implantation procedure provided on September 24, 2019.
You asked the Plan to waive the copayment for the seed implantation procedure. You say that you were not in an outpatient hospital for this procedure. You say you were not told the facility was connected with the hospital. 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 $350 copayment for in-network Medicare-covered outpatient surgery. You have been asked to pay a $350 copayment for the seed implantation procedure. The seed implantation procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital.
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 seed implantation procedure provided on September 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethermal esophagogastroduodenoscopy (EGD) services for the treatment of GERD (code 43257).You asked the Plan to pre-approvethe EGD services. You say that the enrollee has severe GERD, esophageal dysmotility, and dysphagia. You say that the enrollee has a very weakened esophagus, so is not eligible for standard GERD treatment such as Nissen or Linx. You saythat, for this reason, you are requesting coverage for the Stretta procedure.The Plan denied your request. The Plan says CPT code 43257 is a non-covered CPT code.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare rules say that the Stretta procedure is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvethermal esophagogastroduodenoscopy (EGD) services for the treatment of GERD (code 43257).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the Enrollee on August 29, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 pay for the drug testing rendered to the Enrollee on
August 29, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a bilateral breast implant exchange.
You asked the Plan to pre-approve the requested services. You say that you have stabbing pain in both breasts. The Plan denied your request. The Plan says that there is no clinical indication for the removal and/or replacement of the current implants.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 pre-approve the requested services. Our physician reviewer found that you have undergone bilateral breast reconstruction with textured Allergan implants. These types of implants from this company are noted to be associated with a 6 times risk of BIA-ALCL. The FDA had recalled these types of implants with a Class I recall, the most serious type of recall. Use of these devices may cause serious injuries or death. Based on the currently available information, the FDA's analysis demonstrated that the risk of BIA-ALCL with Allergan BIOCELL textured implants is approximately 6 times the risk of BIA-ALCL with textured implants from other manufacturers marketing in the U.S. and continued distribution of Allergan's BIOCELL textured breast implants would likely cause serious, adverse health consequences, including death, from BIA-ALCL. Therefore, implant exchange with smooth typed implants should be considered medically necessary in order to prevent a 6-time increase in development of BIA-ALCL, which is a malignancy. This satisfies the above criteria, as the procedure is being performed to prevent malignancy(treatment of illness) and thus would be medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to pre-approve a bilateral breast implant exchange.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forcardiac rehabilitation services provided from October 22, 2019 to October 31, 2019.You asked the Plan to waive the copayments forcardiac rehabilitation services. You say that you cannot afford 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 a $20 copayment for cardiac rehabilitation services. You received cardiac rehabilitation services from October 22, 2019 to October 31, 2019 for a total of 4 visits. Therefore, you are responsible to pay a$20 copayment per each visit. The total amount you owe is: $80.00.You have been asked to pay the total copayment amount of $80.00 for cardiac rehabilitation services. Cardiac rehabilitation services fall within the cardiac rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forcardiac rehabilitation services provided from October 22, 2019 to October 31, 2019