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

We decided that the Plan does not have to waive the coinsurance for wrist hand finger orthosis purchased on October 26, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you were given the orthosis during your hospital stay and did not leave the hospital with it. 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). Medical records confirmed you were ordered wrist hand finger orthosis (L3809) and were to follow up with an orthopedic provider. DME records indicate that is item was dispensed and received by you. A wrist hand finger orthosis (L3809), is a prosthetic device. You are asked to pay 20% coinsurance for the orthosis. 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 wrist hand finger orthosis purchased on October 26, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided in Spain.You asked the Plan to pre-approve the physical therapy services. You say that you are in Spain and need physicaltherapy services. The Plan denied your request. The Plan says the plan covers worldwide emergency and urgent care services outside the United States.Medicare says that plans must pay for emergency and urgently needed services. Medicare says that urgently needed services are those needed because of an unforeseen illness or condition and it is not reasonable to get the services from the plan. The Plan contract says that while outside of the United Statescoverage is limited to emergency andurgent care. The Plan contract says urgently needed servicesare a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. We looked at the file, Medicare rules and the Plan's rules. The file shows that the physical therapyservices are not needed because of an unforeseen illness or condition. The physical therapy services are not an emergency or urgent care. Based on this information, we decided that rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided in Spain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture.You asked the Plan to pre-approve the maxillary partial denture. You say that the tooth that you need extracted will affect the partial that you have. You also say that you need this new partial.The Plan denied your request. The Plan says this service is not a covered 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 contract clearly states that dentures are not among the services covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 heavy duty power operated vehicle.
You asked the Plan to pre-approve a replacement scooter. You say that your current vehicle is over five years
old and has been fixed multiple times. The Plan denied your request. The Plan says there is no documentation
the current vehicle is malfunctioning.
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.
The file does not contain a repair estimate or physician face-to-face documentation. This means that Medicare
rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to preapprove
a Group 1 heavy duty power operated vehicle.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvepersonal care services.You asked the Planto pre-approvethe services. You say that you cannot affordto pay for this out of your own pocket.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that custodial care is not a covered benefit.The requested personal care services are considered custodial care services. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvepersonal care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new shower stall.
You asked the Plan to pre-approve a new shower stall. You say that getting in and out of the tub is very
difficult for you and you have fallen. The Plan denied your request. The Plan says a shower stall is not
considered to be durable medical equipment per Medicare Guidelines.
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. Medicare does
not cover home modifications. A shower stall is considered a home modification, therefore excluded, not a
covered benefit. Therefore, we decided that the Plan does not have to pre-approve a new shower stall.
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 enrollee's clinical condition meets the full acute inpatient rehabilitation criteria. You say that the enrollee's ability to remain in the community setting will be affected, averting unplanned admissions. You say that the enrollee is willing and able to tolerate 3 hours of therapy at a minimum of 5 days per week .The appellant says that the enrollee's prior level of function shows potential for significant improvement. The Plan denied your request. The Plan says the records show that the enrollee can safely receive the services needed in another setting. The Plan says that IRF care 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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound/skin care, and daily therapy can be provided at a SNF. The enrollee is mostly maximum assist for functional transfers and activities of daily living. A less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit from 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Inpatient Rehabilitation Services provided August 14 to August 21, 2019.
You asked the Plan to waive the copayment for the inpatient rehab services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $430 per day copayment for days 1 through 4 of each admission for Inpatient Hospital Care. You have been asked to pay a $1720 copayment for the first four days of an inpatient rehab admission. The inpatient rehab services fall 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 Inpatient Rehabilitation Services provided August 14 to August 21, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulatory, outpatient services for implantation of neurostimulator provided on August 27, 2019.
You asked the Plan to pay for the ambulatory, outpatient services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 ambulatory, outpatient services for implantation of neurostimulator provided on August 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says daily physician oversight by a rehab physician and intense inpatient rehab would not be necessary for this level of injury.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment in an intensive rehabilitation therapy program. There is concern that you would not be fully able to participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on June 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 an office visit provided on June 5, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 19,
2019 through September 22, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that there should be no
copayment for the hospital because the doctors prescribed postoperative medication for knee surgery resulting
in internal bleeding creating two (2) ulcers and was sent by ambulance to the hospital for four (4) days. You
say if you had not been over medicated this emergency could have been avoided. 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 shows that you were admitted on September 19, 2019 and discharged on September 22,
2019. You were asked to pay a $395 copayment per day from September 19, 2019 through September 21,
2019, days 1-3 of your inpatient hospital care. You were discharged on September 22, 2019 and there was no
copayment charge for the day of discharge. Per your contract there is a $395 copayment per day required for
days 1-4. 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 inpatient hospital care from September 19,
2019 through September 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forblood pressure monitor provided on October 29, 2019.You asked the Plan to pay fora blood pressure monitor/blood pressure monitoring during an ambulance transport.You say that the Plan should pay this claim.The Plan denied your request. The Plan says ambulatory blood pressure monitoring is only covered for suspected white coat hypertension and performed at least 24 hours.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code A4670 is automatic bpmonitor, dial We find that CPT code A4670 is not supported in the medical record. Specifically,the enrollee did not receive a blood pressure monitor during transport and blood pressure monitoring in an ambulance is not separately payable. Based on this information, we decided that Medicare rules for coverage of a blood pressure monitor/blood pressure monitoring during an ambulance transport. have not been met.Therefore, we decided that the Plan does not have to pay forblood pressure monitor provided on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that 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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for a percutaneous endoscopic gastrostomy tube (PEG-tube) site infection. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required.The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 4, 2019.You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that you are responsible for the copayment.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 $200 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way Medicare-covered ground trip 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 ambulance transport provided on October 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair rental provided on June 13, 2019 by an out of network provider. You asked the Plan to pay for the wheelchair rental from an out-of-network provider. You say that the services were medically necessary.The Plan denied your request. The Plan says you did not have 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 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. 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 the wheelchair rental provided on June 13, 2019 by an out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospitalist services (99239) provided September 24, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary and correctly billed. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is Hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the record does not note that more than 30 minutes was spent on the service at issue. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for hospitalist services (99239) provided September 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on September 24, 2018.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 did not pre-approve the drug test.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 a drug test provided on September 24, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RT300 FES therapy system (E1399).
You asked the Plan to pre-approve RT300 FES therapy system. You say that the RT300 FES Therapy system is a medically necessary standard of care for this enrollee that provides multiple medical, physical and functional benefits for him. The Plan denied your request. The Plan says the FES therapy system is not the standard of care there is insufficient high quality literature to suggest long term health benefits for the proposed treatment/device.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. Based on this information, we decided that Medicare rules for coverage of RT300 FES therapy system have not been met. Therefore, we decided that the Plan does not have to pre-approve RT300 FES therapy system (E1399).