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

We decided that the Plan does not have to reduce the copayment for the cardiac stent procedure you had at an outpatient hospital facility on May 3, 2021.

You asked the Plan to reduce the copayment for the cardiac stent procedure. You say that you thought your copayment was only $250, so you are requesting a waiver of the additional $75 you are being charged. 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 $325 copayment for outpatient surgery in an outpatient hospital facility. 

You have been asked to pay a $325 copayment for the cardiac stent procedure. The cardiac stent procedure falls within the outpatient surgery in an outpatient hospital facility 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 reduce the copayment for the cardiac stent procedure you had at an outpatient hospital facility on May 3, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you received on July 2, 2020.
You asked the Plan to waive the copayment for the ER services. You say that you were told that there would be no copayment because you received a Coronavirus test while in the ER. The Plan denied your request. The Plan says you were charged this copayment correctly. Records show that you were triaged in the emergency room and assessed for non-Coronavirus related treatment prior to discharge.
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 $90 copayment for emergency room visits. You have been asked to pay a $90 copayment for the ER services. There is no provision in your contract for a waiver of this amount just because you received a test for Coronavirus while you were in the ER. 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 emergency room (ER) services you received on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for cardiac catheterization services you received at an out-of-network hospital on February 12, 2018.
You asked the Plan to waive the coinsurance for the cardiac catheterization services. You say that you paid this hospital $12,000 directly, so you shouldn't have to pay any more. The Plan denied your request. The Plan says you were assessed this coinsurance correctly. The Plan also says that the out-of-network hospital claims that they have no payments on file from you. The Plan states it has attempted to contact you to obtain proof of payment but has not been successful in reaching you.
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 30% coinsurance for procedures and tests at an out-of-network hospital.
You have been asked to pay 30% coinsurance for the cardiac catheterization services. The cardiac catheterization services falls within the procedures and tests at an out-of-network hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. The out-of-network facility says that it has no proof of payment from you. Your claim that you already paid them directly is not an appealable issue. This is a grievance that must be handled by the provider and your health plan. Our decision is limited only to whether or not the Plan can assess cost sharing. 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 cardiac catheterization services you received at an out-of-network hospital on February 12, 2018.
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 medical records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for aspiration pneumonia and a urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the mental health office visit services provided from December 8, 2020, to March 9, 2021.

You asked the Plan to pay for the mental health office visit services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.

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. In this case, the Plan says the claim was not billed in accordance with Medicare guidelines. However, the Plan has a due diligence to provide supporting evidence for their reasoning for denial. The Plan has not provided an explanation for why Medicare payment guidelines have not been met per the manual the plan has cited. Without this information we are unable to verify if the claim was not payable per Medicare guidelines. Therefore, we decided that the Plan has to pay for the mental health office visit services provided from December 8, 2020, to March 9, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair accessory, group 27 sealed lead acid battery (E2371) purchased February 11, 2021.

You asked the Plan to pay for the wheelchair batter. You say that you checked with the Plan's customer service and was told that your plan covered the scooter's replacement batteries. The Plan denied your request. The Plan says the provider is not a Medicare certified provider.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the power wheelchair accessory, group 27 sealed lead acid battery (E2371) purchased February 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).
You asked the Plan to pre-approve the PMD. You say that the enrollee has mobility limitations caused by lymphedema that significantly impairs ability to participate in toileting, feeding, dressing, grooming, and bathing within the home. You say that, without the power scooter, the enrollee would not be able to complete activities of daily living. You say that the enrollee has sufficient upper strength to propel and would be able to safely use the power scooter. The Plan denied your request. The Plan says the condition of being overweight does not meet the guidelines for coverage of a power scooter. The Plan says that the notes do not show that the mobility device is needed for daily activities within the enrollee's home.
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 the PMD.
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation from the enrollee's physical therapist indicates that the enrollee has breathing difficulty with ambulation but does not require a power mobility device for mobility related activities of daily living in the home. The enrollee is able to ambulate with a rollator and requires the power operated vehicle primarily for outdoor mobility. The physical therapy evaluation states that the enrollee does not have adequate space for the power mobility device in the home and is using it for outside the home. 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 PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (PMD).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you are not able to fully function and care for yourself. The Plan denied your request. The Plan says you do not need daily skilled services in an inpatient setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a modified independent to supervision level with functional mobility. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve FreeStyle Precision Neo strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no prior use of OneTouch of Contour Brand test strips.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 test strips. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is using the FreeStyle Libre for a presumably medically necessary indication and will need from time to time to confirm the readings with a glucometer. It would not be medically reasonable to require him to carry a second meter (One Touch or Contour Brand) to confirm the FreeStyle Libre readings. It makes more sense, and will likely result in better medical care for him to be able to confirm his readings with the same brand of test strips. 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 test strips have been met. Therefore, we decided that the Plan has to pre-approve FreeStyle Precision Neo strips for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on October 4, 2019.

You asked the Plan to pay for the radiology services. You say that the Plan should pay this bill. The Plan denied your request. The Plan says an itemized bill was requested but not received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

You have only provided the Plan with a collection agency bill not an itemized provider bill. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services provided on October 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durvalumab.
You asked the Plan to pre-approve Durvalumab. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Durvalumab. Our reviewer says that the requested use of Durvalumab is not supported. Our physician reviewer found the requested use of Durvalumab is not FDA-approved for the enrollee's diagnosis and is not supported by one of the major drug compendia or by clinical research. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durvalumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Durvalumab.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 1, 2021.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these
services are not payable.
The Plan must follow Medicare rules. Medicare rules say that Transportation, including transportation by
ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic
services not available at the facility where the patient is an inpatient, is covered under Part A.
We looked at the file and Medicare rules. The records show that the enrollee was an inpatient when the
ambulance services were provided. This means that payment for the ambulance services is included in the Part
A hospital payment and is not separately payable. Based on this information, we decided that Medicare rules
for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to
pay for the ambulance services provided on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to be more mobile and stable. The Plan denied your request. The Plan says you cannot tolerate three or more hours per day.
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 physician reviewer found that you were admitted to the acute care hospital for a total knee replacement. Your medical problems are stable. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Capecitabine (J8521).
You asked the Plan to pre-approve Capecitabine. You say that capecitabine is medically necessary. The Plan denied your request. The Plan says that this drug is not indicated for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Capecitabine. Our reviewer says that Capecitabine is medically necessary. Our physician reviewer found the requested drug is safe and effective and otherwise reasonable for the enrollee. The literature and compendia support the efficacy of hypofractionated radiotherapy with capecitabine in elderly patients with urothelial carcinoma. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Capecitabine have been met. Therefore, we decided that the Plan has to pre-approve Capecitabine (J8521).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged evaluation services rendered on January 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99417 is not supported.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure code 99417 (prolonged evaluation services) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation services rendered on January 20, 2021.