Persius/hicric huggingface dataset:
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 LTACH care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With additional time in the current setting, clinical stability can be ensured, and the appropriate lower level of care can be determined.
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 continuing to receive acute care services, and these have not been denied. the medical records do not indicate that the enrollee requires services that are not currently being provided but would be available at the LTACH facility. The elements of the coverage rules are not satisfied, and the requested service cannot be recommended.
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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on October 9,
2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says that procedure code K0553 is not supported.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan states that code K0553 (CGM supplies) is not supported by the
submitted documentation; however, there is a detailed written order for these supplies with this code.
Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supplies rendered on
October 9, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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 can safely receive this care in another 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 is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0428, A0425) provided on November
4, 2020.
You asked the Plan to pay for ambulance services. You say that the enrollee did not arrive at the hospital until
November 4, 2020. The Plan denied your request. The Plan says the enrollee was a registered inpatient
beginning November 3, 2020.
The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services, including
transportation, furnished to inpatients must be furnished directly by the hospital or billed through the hospital
under arrangements.
We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient on the date of
service at issue, meaning the hospital is responsible for payment of this service. Based on this information, we
decided that Medicare rules for coverage of ambulance services have not been met. Therefore, we decided that
the Plan does not have to pay for ambulance services (A0428, A0425) provided on November 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis
vaccine (Tdap) received on March 25, 2021.
You asked the Plan to pay for the Tetanus, diphtheria toxoids and acellular pertussis vaccine. You say that it
was your understanding that this service was covered. The Plan denied your request. The Plan says the services
received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tetanus,
diphtheria toxoids and acellular pertussis vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tetanus,
diphtheria toxoids and acellular pertussis vaccine. Therefore, we decided that the Plan does not have to pay for
the Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) received on March 25, 2021.
Benefits for the Tetanus, diphtheria toxoids and acellular pertussis vaccine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Part B drug services rendered on April 19, 2021.

You asked the Plan to waive the copayment for these services. You say that the cost share was less in the past. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for each Medicare-covered Part B drug.

Review of the file shows that you received Part B drug services on April 19, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare-covered Part B drug 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 Part B drug services rendered on April 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for surgical services (66984) provided
December 10, 2020 and December 17, 2020.

You asked the Plan to waive the copayments for the surgical services. You say that the copayment should be
waived as you were told the service would be covered in full. 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 $275
copayment for Outpatient surgery.

You have been asked to pay $550 for 2 separate surgical procedures ($275 each). The surgical services fall
within the Outpatient surgery 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 copayments for surgical
services (66984) provided December 10, 2020 and December 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures (D5110, D5120).
You asked the Plan to pre-approve the dentures. You say that this is medically necessary. The Plan denied your
request. The Plan says this service exceeds the benefit allowance.
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. The Plan covers dentures once
every five years.
Dentures were last received less than five years ago on April 22, 2017. Based on this information, we decided
that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does
not have to pre-approve dentures (D5110, D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LymphaPress pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary, as this prescriber is the only provider of this specific device. The Plan denied your request. The Plan says there are in-network providers available.

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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the service is being requested form an out of network provider. The plan indicates that the requested service can be obtained in network. The provided records do not establish the medical necessity and reasonableness of this request as defined by Medicare rules. The elements of the coverage criteria are not satisfied. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the LymphaPress pneumatic compression device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says there are a limited number of trips covered by the plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 52 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the spine rendered on May 10, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 $125
copayment for advanced imaging services (this includes MRI) at an outpatient hospital setting.

Review of the file shows that you received an MRI on May 10, 2021. You have been asked to pay a $125
copayment for these services. These services fall within the advanced imaging services (this includes MRI) at
an outpatient hospital setting 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
magnetic resonance imaging (MRI) of the spine rendered on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 87150 is not supported.

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 87150 is culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed. 

We find that CPT code 87150 is not supported in the medical record. Specifically, there is no documentation of culture typing with identification by DNA or RNA probe. 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 pay for the laboratory services rendered on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on February 2 to February 4, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you cannot afford the copayment at issue. The Plan denied your request. The Plan says the correct copayment 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 $325 copayment for each day of days 1 to 5 of each Medicare-covered inpatient hospital stay. 

You have been asked to pay $650, or a $325 copayment for each day of 2 days of inpatient hospital care. You have already paid $75 toward this charge and have $575 remaining. 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 provided on February 2 to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the telehealth service provided by a nephrology specialist on April 7, 2021.

You asked the Plan to reduce the copayment for the telehealth service provided by a nephrology specialist. You say that the phone call was with an assistant and a quick conversation, so it is not worth the $40 copayment. The Plan denied your request. The Plan says you were charged this copay 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 $40 copayment for Physician Services. 

You have been asked to pay a $40 copayment for the telehealth service provided by a nephrology specialist. The telehealth service provided by a nephrology specialist falls within the Physician Services specialist benefit
category. The medical record shows you had the telehealth service with a nephrology physician. 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 reduce the copayment for the telehealth service provided by a nephrology specialist on April 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 26, 2020.

You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, 
fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness 
until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on August 26, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on June 15, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation. During the election, feefor-
service Medicare also covers attending physician services and all care unrelated to the terminal illness until
the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for laboratory services provided on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87481, 87640, 87653, 87798, 87801) rendered by the out-of-network (OON) provider on February 10, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal.

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 the laboratory services (87481, 87640, 87653, 87798, 87801) rendered by the out-of-network (OON) provider on February 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for negative pressure wound therapy provided on February 18, 2021.

You asked the Plan to pay for negative pressure wound therapy. The Plan denied your request. The Plan says pre-certification is required for all services from a non-contracted 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 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 negative pressure wound therapy provided on February 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a fitness membership (S9970) for your 2019 benefit allowance.

You asked the Plan to reimburse you for a fitness membership. You say that you spoke with a Plan representative who advised that you could submit a reimbursement claim after the date of March 31, 2020. The Plan denied your request. The Plan says you missed the deadline of March 31, 2020, to be reimbursed for your 2019 fitness membership.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses you up to $250 each calendar year towards your cost for membership in a qualified health club or fitness facility. Reimbursement requests must be received no later than March 31st of the following year.

The service at issue in this appeal are gym benefits. The records show that submitted your reimbursement towards your 2019 fitness membership on February 22, 2021. The EOC confirms that reimbursement requests must be received no later than March 31st of the following year. Therefore, we decided that the Plan does not have to reimburse you for a fitness membership (S9970) for your 2019 benefit allowance.