Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mental health care visit provided on September 17, 2019.You asked the Plan to waive the copayment for the mental health care visit. You say that you have been going to this practice for a year and a half and have never been charged a copayment. 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 $35 copayment for each individual or group therapy visit. You have been asked to pay a $35 copayment for the mental health care visit. The mental health care visit falls within the "Outpatient mental health 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 the mental health care visit provided on September 17, 2019.Our decision is only about the September 17, 2019 service. If you have any questions about prior years billing, please contact the plan directly.
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. The Plan denied your request. The Plan says there is no need for intensive, comprehensive therapy.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 physician reviewer found that the enrollee was admitted to the acute hospital for back surgery. The enrollee is generally medically stable, with no neurological deficits or bowel or bladder involvement. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or a need for acute rehab nursing care. While she may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 copayments for an inpatient hospital stay and for laboratory services provided from September 10, 2019 to September 26, 2019.
You asked the Plan to waive the copayments for an inpatient hospital stay and laboratory services. You say that you disagree with the denial of charges. The Plan denied your request. The Plan says the claims were processed correctly, and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for days 1-4 for inpatient hospital care. The enrollee's contract with the Plan also clearly says that enrollees must pay a $35 copayment for laboratory services provided in an outpatient hospital facility. The enrollee had an inpatient hospital stay from September 10, 2019 to September 25, 2019. Therefore, the enrollee is responsible to pay a $350 copayment for days 1-4 (September 10, 2019 to September 13, 2019). $350 (copayment) x 4 (inpatient days) = $1,400.00. The enrollee received laboratory services on September 26, 2019. Therefore, the enrollee is responsible to pay the allowed amount of $22.35, which is less than the $35 copayment. The total amount the enrollee owes is $1,422.35.
The enrollee has been asked to pay the total amount of $1,422.35 for an inpatient hospital stay and laboratory services. An inpatient hospital stay falls within the inpatient hospital care benefit category. Laboratory services fall within the outpatient hospital services 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 copayments for an inpatient hospital stay and for laboratory services provided  from September 10, 2019 to September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.You asked the Plan to pre-approve Zilretta. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirement.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Zilretta. Our reviewer says that Zilretta is not medically reasonable and necessary. Our physician reviewer found that the enrollee is noted to have osteoarthritis. A request has been made for Zilretta, a long-acting corticosteroid injection, to treat the osteoarthritis. The health plan requires that Kenalog be used first. There is noevidence that the enrollee is allergic to or intolerant of Kenalog. There is no evidence that the enrollee has tried and not responded to Kenalog. There is no documentation as to why Kenalog would not be expected to be safe and effective for the enrollee.Therefore, the requested Zilretta is not shown to be currently medically necessary and reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta havenot been met.Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for ophthalmological diagnostic tests and procedures provided by the hospital on April 16, 2019.You asked the Plan to waive the coinsurance for ophthalmological diagnostic tests and procedures. You say that you were diagnosed with glaucoma and feel that the services should be considered as screenings.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 20% coinsurance for diagnostic tests and procedures. You received ophthalmological diagnostic tests and procedures on April 16, 2019. Ophthalmological diagnostic tests and procedures are not considered preventative. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $967.09 and 20% of that is $193.42.You have been asked to pay the total coinsurance amount of $193.42 for ophthalmological diagnostic tests and procedures. Ophthalmological diagnostic tests and procedures fall 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 coinsurance for ophthalmological diagnostic tests and procedures provided by the hospital on April 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair.
You asked the Plan to pre-approve the transport chair. You say that the chair allows for transport and can fit in the SUV. The Plan denied your request. The Plan says the medical records do not document that you are unable to use a standard wheelchair.
The Plan follows Medicare rules. Medicare rules say that if documentation of the medical necessity for a transport chair (E1037, E1038 and E1039) is requested, it must include a description of why the beneficiary is unable to make use of a standard manual wheelchair on their own.
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 transport chair. Our physician reviewer found that the enrollee has Alzheimer's dementia, and diabetes with related peripheral angiopathy. The progress note also indicates the enrollee has joint pain due to arthritis. No focal neurological deficits are appreciated on exam. The records do not indicate the enrollee is incapable of using a standard or lightweight manual wheelchair. Therefore, a transport chair is a convenience item and not 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 the transport chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a transport chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided September 21, 2019 to September 29, 2019.You asked the Plan to waive the copayment for the inpatient hospital services. You say that your husband was taken to the hospital and the ER team diagnosed him with as having a heart attack. You have now received a bill for $1,260 and have not paid any of it trusting in the plan.The Plan denied your request. The Plan says the claim was paid and processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay $180 each day for days 1-7 of a covered inpatient stay. You pay $0 each day for days 8-90 of a covered inpatient stay. There is a $1,260 maximum out of pocket limit per benefit period. for Inpatient hospital care. The enrollee has been asked to pay $1260 for the inpatient hospital services. The inpatient hospital services fall within the Inpatient hospital care 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 copayment for the inpatient hospital stay provided September 21, 2019 to September 29, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve Prolia. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not have a history of osteoporotic fracture and has not tried zoledronic acid.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requiresa trial of drug zoledronic acid or a history of osteoporotic fracture before they will approve the requested drug. The documentation does not support that the enrollee has a history of osteoporotic fracture or has triedzoledronic acid. The documentation also does not show that zoledronic acid would likely be less effective or have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs custom molded orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision exam (99214) and vision services (92250) provided December 12, 2018.You asked the Plan to waive the copayment for the vision services. You say that a representative told you that you are entitled to a free exam every year and you have been paying $35 copay for years and you feel you are owed a refund for the past several years.The Plan denied your request. The Plan says this claim was processed correctly with the correct copayment per the plan benefit.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 $35 for Vision care. The enrollee has been asked to pay $35 for the vision services. the vision services fall within the Vision care 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 copayment for vision exam (99214) and vision services (92250) provided December 12, 2018.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for spinal surgery (63047, 22614, 22842, and 22612) provided on July 23, 2019.You asked the Plan to pay for surgical assistant services. You say that a surgical assistant was medically necessary for these procedures.The Plan denied your request. The Plan says surgical assistant services are not covered when provided by a RNFA.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay for surgical assistant services for spinal surgery (63047, 22614, 22842, and 22612) provided by an RNFA on July 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on May 9, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that you do not remember receiving this service. 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 $50 copayment for Medicare-covered CT scan at a freestanding provider. You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you had the CT scan done on May 9, 2019.This means that you have been asked to pay the correct amount based on your contractwith 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 CT scan provided on May 9, 2019.Your complaint that they are staying to steal money from you is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre continuous glucose monitor system.You asked the Plan to pre-approvea continuous glucose monitor. You say that the enrollee needs a CGM.The Plan denied your request. The Plan says the enrollee does not use insulin 3 or more times per day or check glucose levels 4 or more times a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Criteria have not been met.Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre continuous glucose monitor system
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from September 1, 2019 through September 27, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that you were not informed of the copayment.The Plan denied 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 Plan clearly says that you must pay $164 per day for days 21-100 in a skilled nursing facility.You have been asked to pay $1,114.75, which is less than the standard copayment for the SNF stay because you met your maximum out-of-pocket. The SNF stay falls within the "Skilled Nursing Facility" 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 SNF stay provided from September 1, 2019 through September 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you were at an Urgent Care facility which called an ambulance for you. You say that when the ambulance personnel told you that you needed to go to the hospital, you requested that your daughter take you. You say that you cannot afford the bill and if you had known that it would be denied you would have allowed the ambulance to transport you.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 2, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve C3-T1 anterior cervical decompression fusion and posterior cervical fusion for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansayswithout an extensive trial of conservative management including addressing the documented peripheral nerve compression, this surgery is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer tocarefully 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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the imaging studies do not show severe compression of the spinal cord. There is no clear myelopathy. There is no documentation of a recent trial of PT for neck pain. There is no spinal instability, fracture, or tumor. The surgery is not needed.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approveC3-T1 anterior cervical decompression fusion and posterior cervical fusion for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty manual wheelchair.
You asked the Plan to pre-approve a heavy duty manual wheelchair. You say that you are not confident in using your power wheelchair and your manual wheelchair needs repair. The Plan denied your request. The Plan says only one wheelchair at a time is covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have had a power wheelchair since 2017. The power wheelchair serves the same purpose as a heavy duty manual wheelchair. Also, the item at issue in this appeal is for use only outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a heavy duty manual wheelchair.