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

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 28, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you should not be responsible for the ambulance ride because it was not your choice to go to the emergency room. 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 a $250 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance 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 ambulance ride provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair rental provided on April 1, 2019 to December 10, 2019 by out of network provider, Transtech Mobility.
You asked the Plan to pay for the power wheelchair rental. You say that the Plan should complete the rental agreement. The Plan denied your request. The Plan says you did not request 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 power wheelchair rental provided on April 1, 2019 to December 10, 2019 by out of network provider, Transtech Mobility.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on March
7, 2019 by the out of network provider.
You asked the Plan to pay for a domiciliary or rest home visit. You are requesting a review of the charges in
order to receive a retro-authorization. The Plan denied your request. The Plan says services were not authorized
because the non-network provider does not work with the member's health plan and the
member was referred by the non-participating nursing home. The member's primary care physician (PCP) did
not refer for services. The health 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 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 a domiciliary or rest home visit (99336) provided
on March 7, 2019 by the out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health physical therapy evaluation.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a stroke with right sided paralysis and had physical therapy from April of 2019 to December of 2019. She was discharged on December 19, 2019 after meeting all goals and was stable for follow-up with outpatient physical therapy. The records do not show that the enrollee has a change in condition for which skilled therapy services are required to effectively provide treatment or care that is medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea home health physical therapy evaluation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lotemax SM Gel.You asked the Plan to pre-approve the Lotemax. You say that you would like reconsideration as the member has potential pain and inflammation associated with a corneal transplant. The Plan denied your request. The Plan says Lotemax Gel is not covered under the member's Medicare Part A or Part B benefit.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 Lotemax SM Gel. Benefits for the Lotemax may be available under Medicare Part D.Contactthe 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 compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested compression stockings described by code A6533 is not covered by Medicare or the plan as this item does not meet the definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided on September 10, 2019.
You asked the Plan to pay for the self-administered drugs. You say that the drugs were medically necessary. The Plan denied your request. The Plan says the medications at issue, Clonidine and Oxycodone, are self-administered and therefore cannot be covered under the Part B Medical Benefit.
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 pay for self-administered drugs provided on September 10, 2019.
Benefits for the self-administered drugs 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance service provided on August 23, 2019 by the out of network provider.
You asked the Plan to pay for the ambulance services. You say that reimbursement of this claim in the amount of $0 is not acceptable. This was a medically necessary transport. The Plan denied your request. The Plan says that enrollee's must receive their medical services from an in-network provider. Non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 BLS non-emergency ambulance service provided on August 23, 2019 by the out of network provider.
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 enrollee currently meets LTACH admission criteria according to Medicare guidelines.The Plandenied your request. The Plan says the denial of authorization for LTACH service is correct.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 thatthe requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Paliperidone.

You asked the Plan to pre-approve the Paliperidone. The Plan denied your request. The Plan says the criterion
is not met for the Paliperidone, as no records were sent for review.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules also say that information must be submitted by the requester in order
to confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. The case file did not include any medical records. The case file
included documentation showing that the Plan made reasonable attempts to obtain medical records. Without
medical records, we are unable to assess the medical necessity of Paliperidone and confirm that Medicare
coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the
Paliperidone have not been met. Therefore, we decided that the Plan does not have to pre-approve Paliperidone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor provided on August 31, 2019.
You asked the Plan to pay for the supply allowance. You say that the supplies are medically necessary and the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor provided on August 31, 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 clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage have 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 septic knee and bacteremia. The enrollee is receiving a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that surgery cannot be completed without
approval of this. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because studies have not proven that this is helpful for treatment of the enrollee's condition.
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 bone marrow aspiration. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found more research is needed to show the safety and efficacy of bone marrow aspirate
procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan
does not have to pre-approve a diagnostic bone marrow aspiration.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by the provider
on September 11, 2019.

You asked the Plan to waive the copayment for an office visit. You say that this was a physical and you should not
be responsible for 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $0
copayment for an annual physical by your primary care provider. If, during the physical exam, you also receive
services to treat a medical condition you will be expected to pay a $10 copayment for the additional services.
The record shows that you received an electrocardiogram during an office visit on September 11, 2019.
Therefore, you are responsible to pay the $10 copayment.

You have been asked to pay a $10 copayment for an office. An office falls within the physician/practitioner
services, including doctor's office visits benefit category. This means that you have been asked to pay the
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment
for an office visit provided by the provider on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on March 22, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on March 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketamine infusion.You asked the Plan to pre-approve the ketamine. You say that the Ketamine treatment is medically necessary.The Plan denied your request. The Plan says Complex Regional Pain Syndrome is not an approved use of Ketamine.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 ketamine. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found Ketamine is not an approved Federal Drug Administration (FDA) treatment for Complex regional pain syndrome (CRPS). Ketamine for the treatment of chronic pain carries a class III recommendation. Class III states, "Not Recommended, the treatment is not useful and should be avoided." The provided office notes state that the enrollee's pain is better with pain medication and with the spinal cord stimulator.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 ketamine have not been met.Therefore, we decided that the Plan does not have to pre-approve Ketamine infusion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentsfor the inpatient hospital care provided from March 29, 2019 to April 11, 2019.You asked the Plan to waive the copayments. You say that you appreciate the care your uncle has received however, the issue youhave is that it seems there was a premature or unnecessary return to inpatient care from his first rehabilitationstay, which subsequently resulted ina setback on his recovery. The Plan denied your request. The Plan says according to the member's Evidence of Coverage(EOC), there is a $350 copayment per admission for inpatient hospital care. The enrollee was discharged and readmitted on the same day, therefore separate copayments apply.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 contract with the Plan clearly says that the enrollee must pay a $350 copayment foreach inpatient hospital admission. If you are discharged from one level of careand readmitted to another level of care, separate copayments apply.  You have been asked to paya $700copayment for the enrollee's inpatient hospital admissions($350 x 2). This means that you have been asked to pay the correct amount based on the enrollee's contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan.The enrollee was discharged from inpatient rehabilitationon April 1, 2019 and wasadmitted into inpatient acute care on the same day. If you are discharged from one level of care and are readmitted to another level of care, separate copayments apply. Therefore, we decided that the Plan does not have to waive the copaymentsfor the inpatient hospital care provided March 29, 2019 to April 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 30, 2019.You asked the Plan to waive the copayment for the office visit. You say that this was supposed to be a part of your wellness exam. You say that you were informed you would have no copayment.The Plandenied your request. The Plan says the copayment 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 Planclearly says that you must pay a $50 copayment for each in-network specialist visit for Medicare-covered services.You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 office visit provided on September 30, 2019