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

We decided that the Plan does not have to waive the coinsurance for the chemotherapy injection and administration provided on January 13, 2020. You asked the Plan to waive the coinsurance for the chemotherapy injection and administration. You say that you cannot afford this amount. 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for Medicare Part B prescription drugs and 20% coinsurance for services you get in the outpatient department of a hospital. The enrollee has been asked to pay a total of $504.00 for the chemotherapy injection and administration. The chemotherapy injection falls within the "Medicare Part B prescription drugs" benefit category. The chemotherapy administration falls 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 coinsurance for the chemotherapy injection and administration provided on January 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve exercise equipment.You asked the Plan to pre-approve exercise equipment. You say that you are unable to go to the gym to exercise.The Plan denied your request. The Plan says the requested item is not for a medical problem.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve exercise equipment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast implant replacement.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 implant replacement is cosmetic and not medically necessary.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have evidence of rupture of both breast implants. The initial surgery was for cosmetic and not reconstructive reasons. The implant removal has been approved by the plan. The implant replacement is considered cosmetic in nature and is not medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve breast implant replacement.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that the enrollee needs a FreeStyle Libre Continuous Glucose Monitoring system. Plan denied your request. The Plan says the enrollee does not insulin inject three or more times a day or needs frequent dosing adjustment.
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. The records show criteria is not 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-approve a FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the normal saline flush-syringe (A4217).You asked the Plan to pre-approve the normal saline flush-syringe. You say that you feel this should be covered. You need to flush your bag that collects your kidneys waste after your surgery and you will have 1 bag that will need to be flushed every day.The Plan denied your request. The Plan says you are currently receiving skilled home nursing services. Medical supplies are bundled while under a home health plan of care.The Plan must follow Medicare rules. Medicare rules say All supplies which would have been covered under the cost-based reimbursement system are bundled under home health PPS (prospective payment system).Therefore, we decided that the Plan does not have to pre-approve the normal saline flush-syringe (A4217).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the request cannot be approved, as your medical condition was stable.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not require intensive physician or nursing supervision in an IRF. You may benefit from PT and OT but the documentation does not indicate that your functional level or tolerance level of therapy requires this on an intensive level 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for Therapy services (97530) provided July 1, 2019 to July 25,
2019 by the provider.
You asked the Plan to pay for the therapy services. You say that services were properly billed. The Plan denied
your request. The Plan says the billed services were 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 97530 is Therapeutic activities, direct (one-on-one)
patient contact.
We find that CPT code 97530 is not supported in the medical record. Specifically, the medical records provided
do not include documentation of a detailed description of the direct (one-on-one) therapeutic services that were
performed. Based on this information, we decided that Medicare rules for coverage of the therapy services have
not been met. Therefore, we decided that the Plan does not have to pay for Therapy services (97530) provided
July 1, 2019 to July 25, 2019 by the provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture, maxillary partial denture, five removals of residual tooth roots (cutting procedure), and two alveoloplasties in conjunction with extractions.
You asked the Plan to pre-approve the complete mandibular denture, maxillary partial denture, removals of residual tooth roots (cutting procedure), and alveoloplasties. You say that this treatment is medically necessary for you. You also say that without these dental procedures you will not be able to eat and get the nutrients you need to stay healthy. The Plan denied your request. The Plan says these services are not covered under your benefit plan.
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 pre-approve a complete mandibular denture, maxillary partial denture, five removals of residual tooth roots (cutting procedure), and two alveoloplasties in conjunction with extractions.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for inpatient hospital services on September
25, 2019.
You asked the Plan to waive the coinsurance for inpatient hospital services. You say that you cannot afford 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 20%
coinsurance for inpatient hospital care.
You received inpatient hospital services on September 25, 2019. The allowed amount is $100 and 20% of that
is $20.
You have been asked to pay the total coinsurance amount of $20 for inpatient hospital services. Inpatient
hospital services fall within the inpatient hospital care benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
coinsurance for inpatient hospital services on September 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LINX procedure and an inpatient hospital stay.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says the provider has recommended an non-covered procedure which can be done as an outpatient procedure.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider this procedure to be medically necessary. As the procedure itself is not covered, an inpatient hospital stay related to the procedure also cannot be considered medically necessary. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approve the LINX procedure and an inpatient hospital stay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.You asked the Plan to pre-approve these services. You say that the in-network exception should be approved.The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.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 50% of the Medicare-allowed amount for each out-of-network primary care provider visit for Medicare-covered services. You are requesting services from an out-of-network provider at the in-network rate. If you choose to receive services from the requested provider, you will be asked to pay 50% of the Medicare-allowed amount for these services. These services fall within the out-of-network primary care provider visit for Medicare-covered services benefit category. This means that you will be 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. The Plan has network providers available from which you may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compressor provided on August 24, 2019, by an out of network provider.You asked the Plan to pay for the compressor (E0565). You say that the Plan should pay this claim.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 item at issue in this appeal. The Plan did not pre-approve the item a tissue. We found no exception that would require the Plan to pay for this item.Therefore, we decided that the Plan does not have to pay for the compressor provided on August 24, 2019, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided 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 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 an office visit 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 pay for the office visit provided on September 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 office visit provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing coded 81240, 81241, 81401, 81227, 81225, 81355, 81230, 81226, 81231, 81479, 81328, and 81291 provided on October 9, 2019.
You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that CYP panel reporting must be coded correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory testing coded 81240, 81241, 81401, 81227, 81225, 81355, 81230, 81226, 81231, 81479, 81328, and 81291 provided on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvethe complete upper and lower denture.You asked the Plan to pre-approvethe complete upper and lower denture. You say that it is difficult for her to take medication without the dentures. You say that without the dentures she cannot eat and is going to get sick.The Plandenied your request. The Plan says that complete dentures are only covered once every 5 years.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 records do not support that there is a frequency limit for dentures and that a complete upper denture (D5110) and a complete lower denture (D5120) were previously paid for to exceed a frequency limit.Therefore, we decided that the Plan has to pre-approvethe complete upper and lower denture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee requires aggressive pulmonary hygiene, dietary management, and close physician monitoring.The Plan denied your request. The Plan says the enrollee cannot be actively weaned from the breathingmachine.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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for anoxic brain injury following an out-of-hospital cardiac arrest. The enrollee was intubated/ventilated upon presentation and subsequently received a tracheotomy. The enrollee remains on a ventilator. It is not clear than ventilator weaning or decannulation are possible. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.Welooked 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and annual wellness visit provided on June 12, 2019 by an out of network (OON) provider.You asked the Plan to pay for the office visit and annual wellness visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of 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 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 office visit and annual wellness visit provided on June 12, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered to you on October 23, 2019.
You asked the Plan to waive the copayment for these services. You say that you weren't treated properly. 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 $25 copayment for in-network specialist's office services.
Review of the file shows that you received specialist services on October 23, 2019. You have been asked to pay a $25 copayment for these services. These services fall within the in-network specialist's office 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 specialist services rendered to you on October 23, 2019.
Your complaint about the physician 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided on April 23, 2019.
You asked the Plan to pay for the air ambulance services. You say that you were desperate to take the enrollee home to family and moral support. The Plan denied your request. The Plan says the enrollee was transferred from an acute care inpatient hospital to a facility near the enrollee's home.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if the enrollee is transferred to the nearest appropriate facility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on April 23, 2019.