Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvemicrowave ablation of tumors for the enrollee.You asked the Planto pre-approvethe services. You say that the alternative is a surgical wedge resection, which is associated with a much higher cost and morbidity.The Plandenied your request. The Plansaysthe requested procedure is considered investigational.The Planmust 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 wascorrect in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the literature does not address this specific problem. Ablative techniques have been used from other primaries such as colon and renal. However, low grade neuroendocrine tumors are indolent diseases. This is incurable. This procedure is 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvemicrowave ablation of tumors for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from October 26, 2019 to November 3, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the enrollee's maximum out-of-pocket had already been met. 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 a $285 copayment per day, days 1 to 7 and a $0 copayment per day, days 8 to 90 at an in-network outpatient hospital. The enrollee has been asked to pay a $1,372.83 copayment for the inpatient hospital stay. This is less than the standard amount of $1,995 ($285 x 7 = $1,995). The record shows the maximum-out-of-pocket amount of $4,500 was met with the $1,372.83 copayment. The inpatient hospital stay falls 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 from October 26, 2019 to November 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0426) provided April 26, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were told there was no charge for the service by the hospital. The Plan denied your request. The Plan says the correct cost sharing was applied per the plan contract.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for Ambulance Services. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport 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 an ambulance transport (A0425, A0426) provided April 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the bladder irrigation provided on January 17, 2020.
You asked the Plan to waive the copayment for the bladder irrigation. You say that you want to know why there is an increase in cost over the past two years. You say that the annual change in cost should be reconsidered. 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 a $300 copayment for in-network, Medicare-covered surgery, provided in an outpatient hospital or an ambulatory surgical center. You have been asked to pay $272.70, which is less than the standard $300 copayment for the bladder irrigation. The bladder irrigation falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The bladder irrigation is considered a surgical procedure that was provided by the hospital. 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 bladder irrigation provided on January 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

e decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you were eating lunch when you began to feel like you were going to pass out so you called 911. You say that when the responders arrived they tested your heart and wanted to take you to the hospital. You stated that you were feeling stable and you declined transportation to the hospital. You say that if you had gone to the hospital, the bill would have been thousands of dollars. You stated that you took the inexpensive route and it makes no sense that it would not be covered.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 December 19, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from December 10, 2019 to December 12, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not know why you are being charged a $500 copayment. You say you were told multiple times that the hospital is in-network 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 day for days 1 to 5 for Medicare-covered hospital care. You have been asked to pay a $250 copayment for each day of the inpatient hospital stay. ($250 x 2 = $500). The inpatient hospital stay falls 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. The record shows you were seen at an out-of-network hospital but has been covered at the in-network benefit level.
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 inpatient hospital stay provided from December 10, 2019 to December 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea functional electrical stimulator.You asked the Plan to pre-approvea functional electrical stimulator (FES). You say that you use a functional stimulator and it will be obsolete soon.The Plan denied your request. The Plan says coverage is limited to spinal cord injury patients.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no evidence of a spinal cord injury in the clinical documentation. Based on this information, we decided that Medicare rules for coverage of a functional electrical stimulator have not been met.Therefore,we decided that the Plan does not have to pre-approvea functional electrical stimulator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forSNF care provided to the enrollee from January 18, 2020 through January 28, 2020.You asked the Plan to pay forSNF care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 topay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment during the dates January 18, 2020 through January 28, 2020 in a SNF. The enrollee did not have complex wound care or other SNF needs during the dates January 18, 2020 throughJanuary 28, 2020. The enrollee's functional level did not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF during the dates January 18, 2020 through January 28, 2020. The enrollee did not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" during the dates January 18, 2020 through January 28, 2020. As a practical matter, this enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facility setting during the dates January 18, 2020 through January 28, 2020.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pay forSNF care provided to the enrollee from January 18, 2020 through January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and crown provided on January 15, 2020 by an OON provider.
You asked the Plan to pay for the first intraoral periapical x-ray and crown. You say that the booklet outlining dental coverage did not inform you of the costs or have a disclaimer. You also say that the dental guidelines state that there is a $1,000 limit on all covered dental services, but does not explain that you would be covered for less than 50% of a comprehensive dental service. The Plan denied your request. The Plan says the claim was processed, and the out-of-network cost share was applied correctly. The Plan also says that since the provider was OON, the difference of the billed amount and allowed amount became your responsibility.
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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and crown provided on January 15, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care, for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that she requires this therapy on an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF care, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve a continuous glucose monitor. You say that you have minimal use of your hands and a continuous glucose monitor would enable you to have and adequate reading more often. The Plan denied your request. The Plan says the records do not show you test four or more times a day and you are not on an insulin regimen therefore you do not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. You are not insulin treated so you do not meet the Medicare coverage criteria for a CGM. 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 continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided to the enrollee from November 4, 2019 to November 9, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the enrollee should not be held responsible for the copayment. The Plan denied your request. The Plan says that the enrollee is responsible for the copayment according to the benefit plan.
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 $350 copayment for days 1 to 5 of inpatient hospital care. The enrollee has been asked to pay a $1,750 copayment for the inpatient hospital services. The inpatient hospital services fall within the days 1 to 5 of inpatient hospital care benefit category. This means that the enrollee has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital services provided to the enrollee from November 4, 2019 to November 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair with upgraded electronics, tilt and recline, and accessories.
You asked the Plan to pre-approve a Group 2 power wheelchair with upgraded electronics, tilt and recline, and accessories. You say that the enrollee needs a Group 2 power wheelchair with upgraded electronics, tilt and recline, and accessories. The Plan denied your request. The Plan says the enrollee does not meet medical necessity criteria for the requested Group 2 multiple power option power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 a Group 2 power wheelchair with upgraded electronics, tilt and recline, and accessories. Our reviewer says that the power wheelchair upgraded electronics and tilt and recline are not medically necessary. Our physician reviewer found a Group 2 power wheelchair with tilt/leg rests (E1007, E1012), and Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) is not medically necessary. The enrollee was noted to have a mobility deficit that interferes with MRADLs. The documentation does not reveal that the enrollee has spasticity, physical exam evidence of edema in the lower extremities on a medical office visit progress note, or uses intermittent catheterization therefore the enrollee does not require the combination tilt/recline. The documentation is not consistent in regards to upper extremity strength and function. The Wheelchair Evaluation notes the upper extremity strength as less than antigravity which is not consistent with the statement that the enrollee can perform a functional weight shift, use a joystick, ambulate with a cane, use a handheld nebulizer/inhaler. It is not clear why the enrollee could not operate separate switches on an expandable controller. Furthermore, the enrollee does not require 3 power features on the wheelchair therefore the request for the Electronic connection (E2311), Expandable controller harness (E2313), and Expandable controller (E2377) is 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 a Group 2 power wheelchair with upgraded electronics, tilt and recline, and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair with upgraded electronics, tilt and recline, and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea side bed rail.You asked the Plan to pre-approvea side bed rail. You say that because of the enrollee's medical condition it is hard to get out of bed.The Plan denied your request. The Plan says bed rails are only covered for covered hospital beds.The Plan must follow Medicare rules. Medicare rules say that for any item to be covered by Medicare, it must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a side bed rail have not been met.Therefore, we decided that the Plan does not have to pre-approvea side bed rail.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjection of Gel-One in the knee.You asked the Plan to pre-approveGel-One injection. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show that the enrollee has failed to respond to aspiration of the knee or intra-articular corticosteroid injection therapy.The Plan follows Medicare rules. Medicare rules say that viscosupplementation of the knee is only covered when all of the clinical criteria listed above have been met. Viscosupplementation will not be covered when the diagnosis is anything other than osteoarthritis.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 Gel-One injection. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested Gel-One viscosupplementation. Our physician reviewer found there is no detailed documentationof radiologic evidence of osteoarthritis of the knee, such as joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cysts. Additionally, the enrollee meets a coverage limitation for the request because the primary source of pain is believed to be the left lateral tibial plateau fracture. Therefore, the requested Gel-One injection is not medically reasonable and 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 Gel-One injection have not been met.Therefore, we decided that the Plan does not have to pre-approveinjection of Gel-One in the knee.