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

We decided that the Plan does not have to waive the copayment for the ambulance transportation received
December 25, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that the ambulance
provider did not provide advanced life support during the transportation. The Plan denied your request. The
Plan says your copayment for ambulance transportation is the same regardless of the level of care provided
during the transportation.
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 Ambulance Services.
You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation
falls within the Ambulance Services benefit category. The copayment you owe does not vary based on the level
of care received during the transportation. The Plan contract states that you pay $300 for any ground
transportation. 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 ambulance transportation received
December 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that it is not wise to send the enrollee home at this time. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee does not need any special treatment from a nurse. The Plan says that the enrollee does not need a therapist to help her walk in a SNF. The Plan says that the enrollee can transfer to a chair from a bed on her own and can safely receive the care she needs in a different setting.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. The enrollee received physical therapy in the acute hospital. The enrollee was at a contact guard/touch assist level with functional mobility, including gait to 20 feet x 2 with a rolling walker. There are no identifiable skilled nursing service needs. While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new power wheelchair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical documentation that the enrollee cannot use the assigned power wheelchair.

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that you require a replacement power mobility device, as the documentation does not indicate that you were unwilling to participate completely in the therapist wheelchair evaluation per the 3/26/21 document.

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a new power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Freestyle Libre sensors provided to the enrollee on January 12, 2021.
You asked the Plan to pay for these services. You say that these services should be covered. The Plan denied your request. The Plan says that payment is precluded due to an unsolicited telephone contact from the supplier.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. 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 Freestyle Libre sensors provided to the enrollee on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 3, 2020.
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 the claim was billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on December 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bedside table.
You asked the Plan to pre-approve bedside table. You say that you are bedbound and require a bedside table. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because a bedside table is a convenience item and is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a bedside table.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 8, 2020, by an OON
provider.
You asked the Plan to pay for drug testing. You say that you are appealing with supporting records to prove
this service was medically necessary. The Plan denied your request. The Plan says the denial of payment for
this service is correct, because this provider is out-of-network with the Plan and the ordering physician was
also out-of-network with the Plan.
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 items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for drug testing provided on January 8, 2020, by an
OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhinoplasty (CPT code 30420).

You asked the Plan to pre-approve the services. You say that you are asking the plan to reconsider this service because of how you see yourself in the mirror and that you have constant congestion due to the slight bend in your nose. The Plan denied your request. The Plan says the Medicare guidelines say that cosmetic surgery includes any surgical procedure directed at improving appearance. The Plan says Cosmetic surgery or expenses incurred in connection with such surgery is not covered.

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. Your request is not medically necessary because your records show you do not have a malformed body part. Rhinoplasty performed in order to improve your appearance is considered cosmetic surgery, as opposed to a gender-affirming procedure. We are unable to approve this request. Therefore, we decided that the Plan does not have to pre-approve Rhinoplasty (CPT code 30420).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital observation provided from August 19, 2018, to August 20, 2018.
You asked the Plan to waive the copayment for observation. You say that you should not pay for observation when you were never admitted to the hospital. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $250 copayment for outpatient hospital observation. You have been asked to pay $250 copayment for observation. Observation falls within the Outpatient Hospital
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 copayment for outpatient hospital observation provided from August 19, 2018, to August 20, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from January 25
to January 27, 2021.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you should not have
been discharged from the original hospital stay and therefore should not have to pay the copayment for the
second hospital stay. The Plan denied your request. The Plan says the correct copayment was applied.

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 each day of days 1-5 of an admission for inpatient hospital care.

You have been asked to pay $700, or a $350 copayment for each day of a 2-day inpatient hospital stay. An
inpatient hospital stay falls within the "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 copayment for an inpatient hospital stay from January 25 to January 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least three (3) hours a day /five (5) days a week, or fifteen (15) hours over seven (7) consecutive days, of therapy services.

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on December 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the treatment was deemed to have been rendered in an inappropriate or invalid place of service.
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 supporting documentation or records showing that the services were provided in an inappropriate place of services. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from June 11, 2021, forward.

You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve inpatient mental health care. Our physician reviewer found based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of June 11, 2021, forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were not showing any aggressive behaviors being cooperative and compliant as you awaited placement. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from June 11, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. You say that the hearing aids are medically necessary. The Plan denied your request. The Plan says the items at issue are not covered benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the complete maxillary denture reline provided on November 10, 2020.
You asked the Plan to pay for the complete maxillary denture reline. You say that you would like this service to be covered. The Plan denied your request. The Plan says that benefits for this service are limited to one time per sixty-month period.
The Plan must follow Medicare rules. Medicare rules say that the Plan must provide you with a clear and accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits. We looked at the file and Medicare rules. The Plan did not support their denial argument because the Plan contract does not clearly state that there is a limitation of once every five years for complete maxillary denture relines. You reasonably believed this service would be covered because it was previously covered, and there is no clear guidance stating there is a limitation. Based on this information, we decided that Medicare rules for coverage of the complete maxillary denture reline have been met. Therefore, we decided that the Plan has to pay for the complete maxillary denture reline provided on November 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) care provided
January 1, 2021 to January 29, 2021.
You asked the Plan to waive the copayment for SNF care. You say that you would like this copayment waived.
The Plan denied your request. The Plan says the copayment has processed correctly in this case.
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 $0
copayment per day for days 1-20 and a $160 copayment per day for days 21-100 for SNF care.
You have been asked to pay a total cost share of $3520 for SNF care (22 days between days 21-100 x $160
copayment). The services you received fall within the SNF 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 for skilled nursing facility (SNF) care provided January 1, 2021 to January 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee is experiencing severe pain from lumbar stenosis. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the fluciclovine injection rendered on
November 19, 2020.

You asked the Plan to waive the coinsurance for these services. You say that you disagree with the charges.
The Plan denied your request. The Plan says the coinsurance was 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 20%
coinsurance for each Medicare-covered medical supply.

Review of the file shows that you received a fluciclovine injection on November 19, 2020.

You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered
medical supply benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the
fluciclovine injection rendered on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neurostimulator (E0745) provided September 30, 2020.
You asked the Plan to pay for the neurostimulator. You say that the item was medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid proof of delivery. No itemized shipping documentation was provided. The
record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for a neurostimulator (E0745) provided September 30,
2020.