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

We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) of the brain without contrast (70551) provided on November 24, 2020.
You asked the Plan to waive the copayment for an MRI of the brain without contrast. You say that you had to have two separate visits for an MRI as the nurse was unable to place the intravenous (IV) on the first visit and you had to return for a second visit. You also say you should not be responsible for two copayments The Plan denied your request. The Plan says the copayment 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 a $150 copayment for outpatient diagnostic tests and therapeutic services and supplies. You have been asked to pay a $150 copayment for an MRI of the brain without contrast. The EOC confirms that $150 is the required copayment for this service. The records show that you are responsible for the copayment of the first MRI visit but will not be responsible for the second MRI visit. An MRI of the brain without contrast 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 a magnetic resonance imaging (MRI) of the brain without contrast (70551) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aquatic therapy.

You asked the Plan to pre-approve therapeutic procedure services. You say that you would like the services covered. The Plan denied your request. The Plan says you do not have a qualifying condition for aquatic therapy coverage.

The Plan must follow Medicare rules. Medicare rules say that you must have one of the listed conditions to meet coverage criteria. The records do not show that you have one of the covered conditions. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapeutic procedure services have not been met. Therefore, we decided that the Plan does not have to pre-approve aquatic therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment supplies.

You asked the Plan to pre-approve the supplies. You say that this is medically necessary. The Plan denied your request. The Plan says no information related to the prior sleep studies or use of a CPAP machine have been provided.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

A medical rationale for the requested supplies has not been adequately documented in the case file. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve durable medical equipment supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drug provided on February 8, 2021.
You asked the Plan to waive the coinsurance for the Part B drug. You say that there has not been a cost share applied to the drug for the last eleven years. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs.
The enrollee has been asked to pay $103.98 which is 20% of the allowed amount for the Part B drug. The allowed amount is $519.91. ($519.91 x 20% = $103.98). The Part B drug falls within the "Medicare Part B prescription drugs" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drug provided on February 8, 2021.
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 the records provided support the need for SNF care. The Plan denied your request. The Plan says the services needed can safely be received 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 does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is independently mobile and tending to activities of daily living 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. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical conditions are stable. You do not have complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from an intensive rehabilitation therapy program provided 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve shoe inserts (L3000).
You asked the Plan to pre-approve shoe inserts. You say that you need this because you are in pain. The Plan denied your request. The Plan says the requested inserts are not part of a qualifying brace.
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications (such as L3000) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically
necessary for the proper functioning of the brace. We looked at the file and Medicare rules. The submitted documentation does not show that the requested inserts would be on a shoe that is an integral part of a covered brace. Based on this information, we decided that Medicare rules for coverage of shoe inserts have not been met. Therefore, we decided that the Plan does not have to pre-approve shoe inserts (L3000).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic mammogram provided on February 1, 2021, by an in-network provider.

You asked the Plan to waive the copayment for the diagnostic mammogram. You say that you felt the mammogram was preventive and have never paid before. The Plan denied your request. The Plan says the service was diagnostic and not preventive.

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 a diagnostic mammogram on February 1, 2021, from an in-network specialist. You were asked to pay a $35 copayment for the mammogram. Your 2021 EOC states that enrollees must pay a $35 copay for diagnostic procedures and tests in an in-network specialist's office. 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 diagnostic mammogram provided on February 1, 2021, by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power tilt/recline seating system (E1007), power center mount articulating foot platform (E1012), and power seat elevation system (E2300)
You asked the Plan to pre-approve the requested power wheelchair features. You say that the enrollee needs all the requested features for this power wheelchair. The Plan denied your request. The Plan says criteria for the denied features are not met in this case.
The Plan follows Medicare rules. Medicare rules say that power tilt/recline and power elevating leg rests may be covered when enrollees meet the criteria listed in the Medicare rules section. The rules specifically indicate that a power seat elevation system is not covered by Medicare. 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 power wheelchair features. Our reviewer says that the documentation does not support that the power tilt/recline function with power leg platform is medically reasonable and necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift or the enrollee utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed or the power seating system is needed to manage increased tone or spasticity. 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 power wheelchair features have not been met. Therefore, we decided that the Plan does not have to pre-approve the power tilt/recline seating system (E1007), power center mount articulating foot platform (E1012), and power seat elevation system (E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
You were admitted for a fractured patella. Your medical conditions are stable. You do not have complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. Additionally, there is not a reasonable expectation that you will be able to fully participate in and benefit from an intensive rehabilitation therapy program provided 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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on September 9, 2020, and December 28, 2020.

You asked the Plan to waive the copayment for emergency care. You say that you have been receiving invoices from a collection agency and will not pay any medical expenses until processed correctly. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 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 services on September 9, 2020. The Medicare-allowed amount for the emergency care is less than the set $90 copayment; therefore, you have been asked to pay the lesser amount of $55.18 for the emergency care. Furthermore, you received emergency care on December 28, 2020. You were asked to pay a $90 copayment for the emergency care. Your total cost share responsibility is $145.18 ($55.18 +$90 = $145.18). Your 2020 EOC states that enrollees must pay a $90 copay for each emergency room 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 for emergency care provided on September 9, 2020, and December 28, 2020.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a different level of care.
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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient clinic visit provided on February 2, 2021
.
You asked the Plan to waive the deductible for the outpatient clinic visit. 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 2021 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 outpatient clinic services on February 2, 2021. At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay $118.43 for the services to apply to your deductible. 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 deductible for the outpatient clinic visit provided on February 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. 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. Medicare rules say that MRIs are covered only when they are 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 an MRI of the lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee has prior history of lumbar surgery in 1986. Now neurological exam is negative with no weakness or abnormal reflexes. Medrol dose pack does not qualify as conservative therapy. There is no contraindication to a 6-week trial of monitored physical therapy prior to MRI. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 3, 2020, through July 7, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two 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 been met. Specifically, it was reasonable to expect the patient's treatment would span two midnights, and therefore, the services are considered medically necessary and reasonable. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided July 3, 2020, through July 7, 2020.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional routine transportation trips. You say that you have diabetes and had your foot amputated. You say that you have to continue seeing your foot doctor and your primary care physician to make sure there is nothing else wrong. The Plan denied your request. The Plan says the enrollee's benefit does not cover more than 10 one-way trips per plan year, no matter the reason they are being asked for.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 one-way routine transportation trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.