Persius/hicric huggingface dataset:
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 your health is at risk and admission to an IRF is medically necessary. The Plan denied your request. The Plan says based on your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the records provided indicate that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services, but based on the medical records provided, you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided at an IRF. Care at a lower level would appear to be appropriate in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for professional services for allergen immunotherapy provided on February 2, 2021, and March 12, 2021.
You asked the Plan to waive the copayments for professional services for allergen immunotherapy. You say that you should owe 20% coinsurance for allergy shots and disagree with how the claims were processed. 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 $40 copayment for specialist services. The record shows that you received professional services for allergen immunotherapy on February 2, 2021, and March 12, 2021 for a total of 2 services. Professional services for allergen immunotherapy is considered a specialist service, not a Medicare Part B drug service. Therefore, you are responsible to pay the allowed amount of $10.58, per each service, which is less than the $40 copayment. The total amount you owe is: $10.58 (allowed amount) x 2 (specialist services) = $21.16. You have been asked to pay the total copayment amount of $21.16 for professional services for allergen immunotherapy. Professional services for allergen immunotherapy fall within the physician/practitioner services, including doctor's office visits 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 professional services for allergen immunotherapy provided on February 2, 2021, and March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth #5.
You asked the Plan to pre-approve the dental service. You say that your previous crown broke. You say that
you only have a post in place. You say that this should be a covered benefit. You also say that you are not able
to wear a partial denture because that is the tooth that holds it in place. The Plan denied your request. The Plan
says crown is not listed as a covered service.
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, a crown is not among those covered
under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth
#5.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 in the Medicare rules section. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for back pain and underwent kyphoplasty. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. She may benefit from further therapy but does not require an intensive therapy program in an IRF. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inhalation of nitrous oxide/analgesia (D9230).

You asked the Plan to pre-approve the inhalation of nitrous oxide/analgesia. You say that you feel like this service should be covered based on your needs. The Plan denied your request. The Plan says this is not a covered service under your supplemental benefit.

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 the inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on July 1, 2020.
You asked the Plan to pay for the laboratory services. You say that the tests performed were specifically requested by the member's physician with timely results provided. You say that the services were medically necessary, and the claim should be processed. The Plan denied your request. The Plan says this provider is not a participating provider with the Plan.
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 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 laboratory services provided by an out-of-network provider on July 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide therapeutic continuous glucose monitor sensors.
You asked the Plan to provide therapeutic continuous glucose monitor sensors. You say that the enrollee has had great success with a therapeutic continuous glucose monitor. The Plan denied your request. The Plan says the enrollee is not injecting insulin three or more times a day and there is no attestation the insulin regimen requires frequent dose adjustments.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.
We looked at the file and Medicare rules. The provider has confirmed that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have to provide therapeutic continuous glucose monitor sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 20,
2021.
You asked the Plan to waive the deductible for the office visit. You say that you were told you would be
charged $200 for each doctor visit, which is unacceptable. You say that you are supposed to be paying $40 and
the charge should be removed. The Plan denied your request. The Plan says the deductible 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 there is a combined deductible amount of $203 for covered Part B services
from both in-network and out-of-network providers. Until you have paid the combined deductible amount, you
must pay the full cost for covered Part B services from in-network or out-of-network providers.
The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner
services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $203 deductible applies to office visits. This cost sharing is a contractual
obligation that had not been met at the time the office visit was received on January 20, 2021. Therefore, we
decided that the Plan does not have to waive the deductible for the office visit provided on January 20, 2021.
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 the enrollee meets the LTACH admission criteria under CMS guidelines. You say that the enrollee is stable for transfer to an LTACH for aggressive respiratory care with O2 wean, cardiac support, and close medical monitoring with daily physician involvement. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the records do not show that the enrollee has completed the full course of care in the hospital. The Plan says that the enrollee can stay in the hospital to finish treatments.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement and outpatient rehabilitation services provided from October 12, 2020, to November 2, 2020.
You asked the Plan to waive the copayments for wound debridement and outpatient rehabilitation services. You say that the services were all follow-up care and you were not asked to pay a copayment at the time services were received. 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 for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. Your contract with the Plan also clearly says that you must pay a $35 copayment for outpatient rehabilitation services. You received wound debridement and outpatient rehabilitation services provided from October 12, 2020, to November 2, 2020. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the outpatient surgery charges. Outpatient rehabilitation services are not included in follow-up visits and are subject to a $35 copayment. Therefore, you are responsible to pay your share of the costs-sharing charges.
The total amount you owe is: $1,110. You have been asked to pay the total copayment amount of $1,110 for wound debridement and outpatient rehabilitation services. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for wound debridement and outpatient rehabilitation services provided from October 12, 2020, to November 2, 2020.
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 you need LTACH care. The Plan denied your request. The Plan says the rules for LTACH care have not been met.
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 that in this case the enrollee was admitted with bacteremia and spinal disc infection and pleural effusion. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an OON provider.

You asked the Plan to pre-approve the office visit. You say that you have been receiving continuous treatment
for your skin cancer and would like to continue seeing your dermatologist. The Plan denied your request. The
Plan says the provider is out-of-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 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
the office visit to be provided by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for hospital observation services you received from November 7, 2020, to November 8, 2020.
You asked the Plan to waive the copayment for the hospital observation services. You say that you feel this stay was unnecessary because you could have stayed at home until the following day when techs were available to run the echocardiogram machine. The Plan denied your request. The Plan says you were charged this copayment 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 $395 copayment for outpatient hospital observation services. You have been asked to pay a $395 copayment for the hospital observation services. This copayment applies
regardless of the reason for the observation services. 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
hospital observation services you received from November 7, 2020, to November 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 23, 2020.
You asked the Plan to pay for the home visit. You say that the patient did not have many options to pick another provider to make home visits. You say that the medical records support the medical necessity, and the claim should be considered for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the service was not approved in advance.
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
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 home visit provided by an out-of-network
provider on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. You say that this will assist you properly with safety. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for wound care and specialist services provided by a participating provider on January 4, 2021, to February 4, 2021.

You asked the Plan to waive the copayment for wound care and specialist services. You say that these services were coded as a surgery. You say that you did not have a surgery. The Plan denied your request. The Plan says the correct copayment has been 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 $225 copayment for outpatient surgery and a $35 copayment for physician/practitioner services/specialist.

You have been asked to pay a $225 copayment for wound care and a $35 copayment for specialist services.

Amount Being Asked to Pay: $439.94 ($225 + $179.04 + $35 = $439.94).

Wound care is considered an outpatient surgery; therefore, the correct copayments have been applied. Wound care falls within the outpatient surgery benefit category and specialist services falls within the physician/practitioner services/specialist 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 wound care and specialist services provided by a participating provider on January 4, 2021, to February 4, 2021.