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

We decided that the Plan does not have to waive the copayment for the EGD with biopsy (43239) provided on October 3, 2019. 
 
You asked the Plan to waive the copayment for the EGD with biopsy (43239). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an EGD with biopsy, a surgical procedure in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the 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 $295 copayment for Outpatient surgery.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an EGD with biopsy, a surgical procedure in an outpatient hospital setting on October 3, 2019. You have been asked to pay a $295 copayment for the EGD with biopsy (43239). The EGD with biopsy (43239) falls 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 copayment for the EGD with biopsy (43239) provided on October 3, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport and ER visit provided on September 24, 2019. You asked the Plan to waive the copayment for the ambulance transport and ER visit. You say that he fell multiple times while in rehabilitation. You say that the provider should pay for the hospital visit and ambulance transport. The Plan denied your request. The Plan says the copayments 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $240 copayment for each Medicare-covered one-way trip via ground ambulance and a $90 copayment up to a maximum for emergency care. The enrollee has been asked to pay a $240 copayment for the ambulance transport and a $90 copayment for the ER visit. The ambulance transport falls within the "Ambulance services" benefit category. The ER visit falls within the "Emergency 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 ambulance transport and ER visit provided on September 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for Computed Tomography Angiography (CTA) and Part B drugs (75635, J1200, Q9967) provided December 26, 2019. 
 
You asked the Plan to waive the cost-sharing for the CTA and Part B drugs. You say that the copayment should only be $125. 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 $125 copayment for advanced imaging services and a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $125 copayment for advanced imaging services and a 20% coinsurance for Part B Drugs. 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 cost-sharing for Computed Tomography Angiography (CTA) and Part B drugs (75635, J1200, Q9967) provided December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction (D7210) of tooth #18.You asked the Plan to pre-approve the extraction of tooth #18. The Plan denied your request. The Plan says due to the significant bone loss associated with tooth #18, a surgical extraction is not necessary. The Plan also says that the Medicare coverage criteria for an extraction of tooth #18 has not been met.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 the extraction of tooth #18when the services are medically necessary and reasonable. 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 extraction of tooth #18. Our reviewer says that the extraction of tooth #18 does not meet the Plan's coverage criteria. Our physician reviewer found the extraction of tooth #18 does not require a surgical extraction procedure (D7210). This procedure includes the elevation of a flap, removal of bone and/or sectioning of the tooth. Our reviewer also found that there is extreme bone loss associated with tooth #18 and a routine elevation and forceps extraction would be the customary and usual procedure (D7140). We looked at this physician's review, the file, and Medicare rules. Based on this information,we decided that the Plan's rules for coverage of the extraction of tooth #18 have not been met.Therefore, we decided that the Plan does not have to pre-approvethe extraction (D7210) of tooth #18.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the professional services for immunotherapy injections provided from January 2, 2020 through February 14, 2020. You asked the Plan to waive the coinsurance for the professional services for immunotherapy injections. You say that the shots are needed. You say that you were informed the shots were fully covered. The Plan denied your request. The Plan says that the coinsurance applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for each Medicare-covered service. Covered services include medically-necessary medical care or surgery services furnished in a physician's office, certified ambulatory surgical center, hospital outpatient department, or any other location by a primary care provider. The Plan says you must pay 20% coinsurance for the professional services for immunotherapy injections. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for each professional service for immunotherapy injections. The professional services for immunotherapy injections are physician services that were billed by primary care providers. Therefore, we decided that the Plan has to waive the coinsurance for the professional services for immunotherapy injections provided from January 2, 2020 through February 14, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray you received on December 30, 2019. You asked the Plan to pay for the chest x-ray. The Plan denied your request. The Plan says this is not a covered 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). Your contract with the Plan clearly says that physical exams and other services required by third parties for such things obtaining or maintaining employment or participation in employee programs, required for insurance or licensing, requested sports physicals, or on court order or required for parole or probation, are not covered under any condition.Review of the file shows that you were provided a chest x-ray during a physical exam on December 30, 2019. The exam was required by a third party for admission to an assisted living center. Services required by a third party are not covered under your plan. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the chest x-ray you received on December 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for needle, sterile, any size, each (A4215) provided to the enrollee on December 20, 2019. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The services are not authorized because they are included in the facility PPS payment for a surgery/procedure done at an outpatient facility. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and hospital and outside providers. Payment for this service would have been included in the facility PPS payment for the procedure. Payment for this service is the responsibility of the facility or hospital that provided services. Therefore, we decided that the Plan does not have to pay for needle, sterile, any size, each (A4215) provided to the enrollee on December 20, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (CPT Code 92012) provided on January 21, 2020 by an out-of-network provider. 
 
You asked the Plan to pay for the services. You say that you were told in the beginning the provider was accepting the plan. The Plan denied your request. The Plan says you do not have out-of-network benefits. The plan states you did not call member services prior to receiving the services on January 21, 2020 to verify if the provider was in-network. 
 
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 ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient (CPT Code 92012) provided on January 21, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem tablets. 
 
You asked the Plan to pre-approve the Zolpidem tablets. You say that the enrollee has been taking this medication for a long time and has been stable with no adverse reactions. You also say that this medication has been previously approved through their insurance. The Plan denied your request. The Plan says this medication is a benefit exclusion. The Plan also says that the enrollee's plan does not cover outpatient prescription drugs. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Zolpidem tablets.  
 
Benefits for the Zolpidem tablets 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 18, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 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 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 medical services provided to the enrollee by an out-of-network provider on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable


 You asked the Plan to pre-approve the inpatient psychiatric services. You say that the clinical information demonstrates why the enrollee needs to stay in the behavioral health unit at the inpatient level. The Plan denied your request. The Plan says the clinical information provided does not support the level of care being requested. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  
 
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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on May 1, 2020 with Schizophrenia. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and claimed auditory no visual hallucinations, not command in nature. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. 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 inpatient psychiatric services. have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type (E2300), for the enrollee. You asked the Plan to pre-approve the DME. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan. 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. The rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve wheelchair accessory, power seat elevation system, any type (E2300), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Flexitouch lymphedema pump and leg garments, for the enrollee. 
 
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The records do not indicate that the enrollee has trialed a basic pump, and there is no documentation that the enrollee has edema in their abdomen or chest. Therefore, we decided that the Plan does not have to pre-approve Flexitouch lymphedema pump and leg garments, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 20, 2019 to November 27, 2019. You asked the Plan to waive the copayment for an inpatient hospital stay. 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 a $225 copayment per day for days 1-6 for inpatient hospital care. You had an inpatient hospital stay from November 20, 2019 to November 27, 2019. Therefore, you are responsible to pay a $225 copayment for days 1-6 (November 20, 2019 to November 25, 2019). $225 (copayment) x 6 (inpatient days)= $1,350. You have been asked to pay the total copayment amount of $1,350 for an inpatient hospital stay. An 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. 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 from November 20, 2019 to November 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable


 We decided that the Plan does not have to pre-approve a transcatheter insertion or replacement of a permanent leadless pacemaker (33274). 
 
You asked the Plan to pre-approve a transcatheter insertion or replacement of a permanent leadless pacemaker. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
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 a transcatheter insertion or replacement of a permanent leadless pacemaker. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found leadless pacemakers are currently considered investigation. One study reported successful implantation on 96% of patients (less than conventional lead device placement) as well as significant side effects in 6.7% of patients at 6-month follow up including device dislodgement in 1.7%, cardiac perforation in 1.3% and pacing threshold elevation requiring device removal in 1.3%. Other studies have noted that long term complications remain to be determined. Finally, there is no documentation of any contraindication to a leaded pacemaker system such as no or limited venous access. 
 
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 transcatheter insertion or replacement of a permanent leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve a transcatheter insertion or replacement of a permanent leadless pacemaker (33274).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the golf course fee for December 1, 2019 through December 31, 2019. You asked the Plan to reimburse the services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you rules have not been met. 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's rules for coverage of gym benefits have not been met because you did not submit itemized receipts. Your EOC states, we reimburse you up to $40 per month for qualifying fitness expenses. You will be responsible for paying the qualifying expenses upfront. You must submit an itemized receipt or other proof of payment and proof of participation for reimbursement to the plan. For golf courses, the plan will only cover driving range and green fees. The facility must be open to the public (no private clubs including private golf clubs or private country clubs and no private residences). Therefore, we decided that the Plan does not have to reimburse the golf course fee for December 1, 2019 through December 31, 2019.