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

We decided that the Plan does not have to pay for supplies for a therapeutic CGM (K0553) provided on December 1, 2020.
You asked the Plan to pay for CGM supplies. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
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 for the supplies provided in this case. Specifically, the documents submitted as proof of delivery indicate the requirement of a signature. The documents submitted are not signed. 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 supplies for a therapeutic CGM (K0553) provided on December 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 8, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 laboratory services provided by an out-of-network provider on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for psychotherapy provided on January 5, 2021.
You asked the Plan to waive the deductible for psychotherapy. You say that your coverage for mental health services shows a $40 copayment. You say that you want to know why it wasn't covered. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $750 for out-of-network services. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services from out-of-network providers. Until you have paid the deductible amount, you must pay the full cost of your covered services from out-of-network providers. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient mental health care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time psychotherapy was received by an out-of-network provider on January 5, 2021. Therefore, we decided that the Plan does not have to waive the deductible for psychotherapy provided on January 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from August 25, 2020, through December 10, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you were informed the Plan waived copayments through December and you should not have been charged. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for Medicare-covered physical therapy and/or speech and language pathology visits. You have been asked to pay a $10 copayment for each physical therapy visit. The total amount you owe is $290 ($10/visit x 29 visits = $290). Physical therapy falls 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 physical therapy provided from August 25, 2020, through December 10, 2020.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for syncope, hypocalcemia and urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual physical exam (99397) provided on December 4, 2020.
You asked the Plan to pay for the annual physical exam. You say that you received two annual physicals in 2020. The first one 01/08/20 and the second one 12/04/20. This was to be able to get your annual physical 1 month early since you were leaving for winter vacation for 4 months. The Plan denied your request. The Plan says the benefit has been exhausted as the records show that the annual physical exam was already rendered and paid for date of service January 8, 2020.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for the annual physical exam (99397) provided on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental surgery with an out of network provider.
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. You say that you have seen other providers whose attempts to help you have failed. You also say that it is difficult for you to speak and eat. The Plan denied your request. The Plan says the requested services are dental in nature. The Plan says that routine dental services are not covered. The Plan says that the requested dental provider is out of network. The Plan says that services provided out of network are not covered either. The Plan also says that there are in network providers available.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. The record shows that the requested services are for the purpose of placing implant supported dentures. Therefore, we decided that the Plan does not have to pre-approve dental surgery with an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical first radiographic image (D0220) and periapical each additional radiographic image (D0230) provided November 30, 2020.

You asked the Plan to pay for the periapical x-rays. You say that you have never been charged for your yearly dental exam and believe the services should be covered in full. The Plan denied your request. The Plan says the individual periapical x-rays are not covered under your dental benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical first radiographic image (D0220) and periapical each additional radiographic image (D0230) provided November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would approval for these services to be provided by an out-of-network provider. 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-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve oncology services. You say that you would like approval for these services to be provided by an out-of-network provider. 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-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for Pembrolizumab 1MG injection (CPT code J9271) provided from August 16, 2019 through September 28, 2019.
You asked the Plan to waive the cost-share for the medication. You say that you are appealing your cost-share responsibility for the services you received because your explanation of benefits (EOB) shows you do not owe anything. The Plan denied your request. The Plan says the explanation of benefits (EOB) included your initial correspondence from June 2020 refer to claims which were denied back to the provider for billing errors, the provider has since submitted corrected claims and the services were then payable. The Plan states per your 2019 EOC, you are responsible for 20% of the payable.
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 Pembrolizumab 1MG injections (CPT code J9271 from August 16, 2019 through September 28, 2019. You were asked to pay 20% coinsurance per date of service for the medication. Your 2019 EOC states that enrollees must pay 20% coinsurance for each Medicare-covered Part B drug. The cost share for August 16, 2019, is less than the 20% allowable as it was the last claim processed and you have reached their out-of-pocket maximum. 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 cost-share for Pembrolizumab 1MG injection (CPT code J9271) provided from August 16, 2019 through September 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a treadmill.
You asked the Plan to pre-approve the treadmill. You say that with COVID cases still high it is scary to go to gym, and you feel the treadmill for use in your home should be covered by the Plan. The Plan denied your request. The Plan says treadmills are not a covered benefit. Treadmills do not meet the definition of Durable Medical Equipment because the term DME is defined as equipment which can withstand repeated use, could normally be rented and used by successive patients, and is primarily and customarily used to serve a medical purpose. Additionally, treadmills are not offered as a supplemental benefit under the Wellness Allowance by the Plan at this time.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
We looked at the file, the Medicare rules and the Plan's rules. 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. The Plan does not cover treadmills under the supplemental fitness benefit. Therefore, we decided that the Plan does not have to pre-approve a treadmill.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness and falls. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 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 acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic testing provided by a participating provider on December 9, 2020.
You asked the Plan to waive the copayment for diagnostic testing. You say that you were not in an operating room. The Plan denied your request. The Plan says the correct copayment has been 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 $200 copayment for outpatient diagnostic tests/other diagnostic tests. You have been asked to pay $171.90 which is less than your copayment amount of $200 for diagnostic testing. The correct copayment has been applied to the services that were provided. Diagnostic testing falls within the outpatient diagnostic tests/other diagnostic tests 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 diagnostic testing provided by a participating provider on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Q-grip handrims and a seat pouch.
You asked the Plan to pre-approve the Q-grip handrims and a seat pouch. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says these items are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 the Q-grip handrims and a seat pouch.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services (A0429 and A0425) provided on October 11, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this claim is for a member whose death was pronounced during ambulance services and the QL modifier is required. The Plan denied your request. The Plan says this claim was not billed according to CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A0429 and A0425 is not supported in the record. Specifically, this claim was billed with the QL modifier indicating that the member was pronounced dead after the ambulance was called. This service must be billed with CPT code A0428. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services (A0429 and A0425) provided on October 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa solution.
You asked the Plan to pre-approve Rhopressa solution. You say that the enrollee's pressures have been in good control since starting Rhopressa, and you recommend that the enrollee continue using this drop therapy. The Plan denied your request. The Plan says this medication does not fall under 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 Rhopressa solution.
Benefits for Rhopressa solution 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.