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

We decided that the Plan does not have to pre-approve an electronic connection and expandable controller with harness for a power wheelchair (PWC).You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the items are not covered.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The items at issue are an electronic connection and expandable controller with harness. The file shows that the Plan approved a Group 3 PWC with three power options. The electronic connection is not needed, as the file shows you have adequate limb strength to operate the approved power options. The expandable controller with harness is not covered because the approved PWC accessories already include their own switches. Therefore, we decided that the Plan does not have to pre-approve an electronic connection and expandable controller with harness for a power wheelchair (PWC).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from November 6, 2019 to November 25, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee's condition did not require daily skilled services at an inpatient SNF level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from November 6, 2019 to November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a specialist visit provided on October 25, 2019.
You asked the Plan to waive the deductible for a specialist visit. You say that you only saw the doctor for 5 minutes and disagree with 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. Your contract with the Plan says that there is a $250 deductible for specialist visits. The medical records show that you had a specialist visit on October 25, 2019. The record shows that you had only paid $144.34 toward the $250 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $105.66. 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 $250 deductible for physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on October 25, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a specialist visit provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the office visit, the spinal fusion procedure, and the inpatient hospital services provided from July 23, 2019 and September 26, 2019.
You asked the Plan to reduce the copayments for the office visit, the spinal fusion procedures, and inpatient hospital services. You say that you cannot afford to pay the total bill. You say you are asking for the Plan to lower the amount due. 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 20% coinsurance for services obtained from an in-network primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office, 20% coinsurance for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges, and 20% coinsurance for each in-network Medicare-covered hospital stay.
You have been asked to pay a total of $259.43 for the office visit, the spinal fusion procedures, and inpatient hospital services. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The spinal fusion procedures fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The inpatient hospital services fall within the "Inpatient Hospital Care" benefit category. See chart below. 

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 copayments for the office visit, the spinal fusion procedure, and the inpatient hospital services provided from July 23, 2019 and September 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy services provided on November 18, 2019.You asked the Plan to waive the copayment forthe physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request.The Plan says you received physical therapy on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $40 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received physical therapy on November 18, 2019. You have been asked to pay a $40 copayment for the physical therapy services. The physical therapy services fall within the Outpatient 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 copayment forthe physical therapy services provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea duplex scan to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea duplex scan. You say that you would like pre-approval for these services.The Plan denied your request. The Plan says there are in-network providers available for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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-approvea duplex scan to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transverse abdominis plane (TAP) block.
You asked the Plan to pre-approve transverse abdominis plane (TAP) block. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not
medically necessary.
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 transverse abdominis plane (TAP)
block. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found you have a history of chronic abdominal pain. You had
been seen on November 11, 2019 and January 21, 2020 at which time you underwent left transverse abdominis
plane (TAP) blocks. Initially, you reported some increased pain the day of the injection which lasted about two
hours but then the overall pain improved by about 30 to 40%. You reported left lower and right upper quadrant
pain rated at 6/10. There is no evidence in the peer-reviewed medical literature supporting the use of a TAP
block for chronic abdominal pain. The requested services are not considered the standard of care for the
treatment of your condition. You do not meet criteria for the requested 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 transverse abdominis plane (TAP) block have not been met. Therefore, we
decided that the Plan does not have to pre-approve transverse abdominis plane (TAP) block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device.
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using conservative therapy that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0650 or E0651 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with a compression bandage system, regular exercise, and elevation of the limb. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of conservative therapy. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Promethazine, 25 mg tablet.
You asked the Plan to pre-approve Promethazine. The Plan denied your request. The Plan says promethazine is a drug that you take orally. The Plan says drugs that are taken orally are considered to be self-administered. The Plan also says that self-administered drugs 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 pre-approve Promethazine, 25 mg tablet.
Benefits for Promethazine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair or shower transfer bench.
You asked the Plan to pre-approve a shower chair or shower transfer bench. You say this item is medically necessary. The Plan denied your request. The Plan says this type of equipment is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair or shower transfer bench.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe physical therapy services provided on December 4, 2019.You asked the Plan to waive the copayment forthe physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received physical therapy on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $40 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received physical therapy on December 4, 2019. You have been asked to pay a $40 copayment for the physical therapy services. The physical therapy services fall within the Outpatient 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 copayment forthe physicaltherapy services provided on December 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urinary tract infection (UTI) pathogen panel testing
You asked the Plan to pay for lab testing. You say that these procedures are not experimental/investigational according to Medicare. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests are not approved for coverage and a urine culture and sensitivity is the standard of care but was not performed.
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 pay for lab testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this testing technique raises considerable concerns regarding contamination from 1 specimen to another, creating the potential for false-positive results. The clinical interpretation of results may also be challenging. Medical records received do not indicate that urine culture and sensitivity would be inadequate for this enrollee's circumstances.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lab testing have not been met. Therefore, we decided that the Plan does not have to pay for urinary tract infection (UTI) pathogen panel testing
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for observation services provided on
November 18, 2019.
You asked the Plan to waive the coinsurance for the observation services. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received emergency care and then received observation services on November
18, 2019. You are asked to pay a $225 copayment for the observation 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. Therefore, we decided that the Plan does not have
to waive the coinsurance for observation services provided on November 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TSH blood test-HAA: Human anti-animal antibodies.
You asked the Plan to pre-approve TSH blood test-HAA: Human anti-animal antibodies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 TSH blood test-HAA: Human anti-animal antibodies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have longstanding hypothyroidism on replacement. You like to keep TSH low per the documentation. You are now cutting the replacement therapy and you claim the TSH does not accurately guide therapy due to the possible presence of some antibodies affecting the assay. You have been evaluated by separate experts who do not feel that this test is necessary. It is not a commonly used test. Therefore, you do not meet criteria for the requested 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 TSH blood test-HAA: Human anti-animal antibodies have not been met. Therefore, we decided that the Plan does not have to pre-approve TSH blood test-HAA: Human anti-animal antibodies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0668).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you disagree with this determination and ask that you review the enclosed documentation supporting medical necessity of the requested equipment. The Plan denied your request. The Plan says the enrollee has not tried and failed a 4 week trial of a basic lymphedema pump (either E0560 or E0651) and therefore does not meet the criteria.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0668).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services provided on December 6, 2019.You asked the Plan to waive the copayment for the physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request.The Plan says you received physical therapy on the date of service at issue in this appeal. The Plan states the correct copayment has applied per your contract with the Plan.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 $40 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physical therapy services on December 6, 2019. You have been asked to pay a $40 copayment for the physical therapy services. The physical therapy services fall within the Outpatient 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 copayment for the physical therapy services provided on December 6, 2019.