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

We decided that the Plan does not have to waive the coinsurance for the Trastuzumab-anns injections (Q5177) provided on January 6, 2021 and January 27, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.

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% coinsurance for Chemotherapy drugs rendered by an in-network provider. 

You have been asked to pay $1,044 ($2,610 x 20% coinsurance= $522 x 2) for the chemotherapy injections provided. 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 the Trastuzumab-anns injections (Q5177) provided on January 6, 2021 and January 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repairs for your Group 4 power wheelchair (PWC).

You asked the Plan to pre-approve PWC repairs. You say that you need repairs to get around your home and live your daily life. The Plan denied your request. The Plan says that repairs for a Group 4 PWC cannot be covered because Group 4 PWCs are not covered.

The Plan must follow Medicare rules. Medicare rules say that Group 4 PWCs will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. You are requesting repairs for a non-covered PWC. Based on this information, we decided that Medicare rules for coverage of PWC repairs have not been met. Therefore, we decided that the Plan does not have to pre-approve repairs for your Group 4 power wheelchair (PWC).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist visit you had on December 2, 2020.

You asked the Plan to waive the copayments for the specialist visit. You say that you never saw the doctor on this date, only two nurse assistants. The Plan denied your request. The Plan says you were charged this copayment 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 $50 copayment for visits with a specialist. 

You have been asked to pay a $50 copayment for the specialist visit. This copayment applies if you receive services in a specialist's office even if you don't see the physician themselves. 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 for the specialist visit you had on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) and the percutaneous allergy skin tests (95004) rendered by the out of network (OON) provider on November 19, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 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 office visit (99203) and the percutaneous allergy skin tests (95004) rendered by the out of network (OON) provider on November 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the emergency room visit and inpatient hospital stay provided from December 28, 2020 to December 30, 2020.

You asked the Plan to waive the copayments for the emergency room visit and inpatient hospital stay. You say that the prices you were charged are ridiculous. The Plan denied your request. The Plan says that 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 $90 copayment per emergency care visit and a $250 copayment per day for days 1-7 of inpatient hospital care.

You have been asked to pay a $90 copayment and a $500 copayment for the emergency room visit and inpatient hospital stay. The emergency room visit falls within the emergency care visit and the inpatient hospital stay falls within the days 1-7 of inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the emergency room visit and inpatient hospital stay provided from December 28, 2020 to December 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.

You asked the Plan to pre-approve home health services. You say that the requested home health services are a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for home health services
have not been met.

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 home health services. Our reviewer says that the requested home health services are not medically necessary at this time. Our physician reviewer found that the enrollee does not have documented skilled needs. The enrollee appears to have reached a plateau in function. The enrollee's care needs, as a practical matter, could be provided at a lower 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on February 12, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you received the medications during surgery. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

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 pay for the self-administered drugs provided in an outpatient setting on February 12, 2021.

Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services for treatment of joint pain.
You asked the Plan to pre-approve chiropractic services. You say that the requested treatment is a necessity for you. The Plan denied your request. The Plan says rules for chiropractic services have not been met.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The medical records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve chiropractic services for treatment of joint pain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right shoulder joint replacement surgery to be provided at the inpatient level of care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee has had conservative treatment but with worsening symptoms. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because there is no expectation that the enrollee will require a greater than 2 midnight hospital stay and inpatient level of care can be reconsidered if there are peri- or post-operative complications.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the documentation does not show any significant medical history that would present significant risk factors to the proposed surgery. Furthermore, the enrollee has a history of other surgeries (including left shoulder surgery and knee surgery) without documentation of any significant complications. There is no compelling rationale or extenuating circumstance noted to support the medical necessity of inpatient level of care. The treating physician would not reasonably expect that your necessary hospital care will span at least 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve right shoulder joint replacement surgery to be provided at the inpatient level of care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.

You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says you do not need skilled therapy visits at home.

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 home health services. Our physician reviewer found that you are at a standby assist level for transfers and walking using a two-wheeled walker. You do not have documented skilled therapy needs. Your care needs, as a practical matter, can be provided at a lower 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services (D0274, D1110, D0120) received November 18, 2020 from the opt-out provider.

You asked the Plan to pay for the dental services. You say that you did not know a dentist could opt out of Medicare. The Plan denied your request. The Plan says the provider in this case has opted out of Original Medicare and therefore, the services cannot be covered.

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 only covered under this benefit when they are received from a provider who participates with Original Medicare and accepts Medicare patients. We have confirmed that this provider was opted out of Original Medicare on the date you received these services. Therefore, we decided that the Plan does not have to pay for the dental services (D0274, D1110, D0120) received November 18, 2020 from the opt-out provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient care.

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 records show that the enrollee has ongoing acute issues and is unstable requiring
additional short-term acute care services which can safely be received at the current facility. The patient does
not require services at the LTACH that are not already available at the current facility.

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 LTACH services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health visits for wound care.

You asked the Plan to pre-approve home health care. You say that your wound is in an awkward place and you have difficulty applying dressings yourself. The Plan denied your request. The Plan says the denial of authorization for additional home health skilled care visits is correct.

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 home health care. Our reviewer says that you do not meet the Medicare criteria for additional home health care visits. Our physician reviewer found based on the medical records provided there is no documentation that continued skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition or establish/perform a maintenance program. Records indicate there are no complicated wound issues or requirements for anything other than wound cleansing and application of hydrogel 3 times per week. Non-skilled assistance with wound care as needed appears to be indicated at this point. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve additional home health visits for wound care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires admission to an
LTACH as they expect a prolonged hospital stay and require acute care. The Plan denied your request. The
Plan says the criteria for admission to the LTACH have not been met. The enrollee's medical needs are being
met in the current acute setting. The LTACH would add no additional services. With additional time in the
current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 that the enrollee does not require services at the LTACH that are not already
available at the current facility. Therefore, this request for LTACH services will be considered not medically
reasonable and necessary as there is no advantage to a transfer at this time. Transfer to a lower level of care
may be considered when treatment is completed.
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is mobilizing and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (for example: home, assisted living, or long-term 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) received March 4, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that your crown fell off and your dentist advised that it should be put back on as soon as possible. The Plan denied your request. The Plan says there is no coverage for problem focused limited oral evaluations under your supplemental 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 pay for the limited oral evaluation - problem focused (D0140) received March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office or other outpatient visit (99213) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve office or other outpatient visit. You say that you need to be evaluated for a growth between your eye and nose. The Plan denied your request. The Plan says they have in-network providers available to provide for your medical needs.

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 office or other outpatient visit (99213) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mandible graft surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve mandible graft. You say that the enrollee will be having extensive procedures with this doctor involving the same area. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this service can be provided by an in-network provider.
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
mandible graft surgery to be provided by an out of network (OON) provider