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

We decided that the Plan does not have to waive the copayment for an EGD provided on June 9, 2021.

You asked the Plan to waive the copayment for an EGD. You say that you thought that you would owe $0 for
the procedure. 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 $0
copayment for colonoscopies and a $350 copayment for outpatient surgery, including services provided at
hospital outpatient facilities and ambulatory surgical centers.

The record shows that you received an EGD at an outpatient hospital facility on June 9, 2021. 
An EGD is considered an outpatient surgical procedure and is not included in colonoscopy screenings.
Therefore, you are responsible to pay the $350 copayment.

You have been asked to pay a $350 copayment for an EGD. An EGD falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on June 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130)
and wheelchair van mileage (S0209) provided on May 14, 2020.

You asked the Plan to pay for the transportation services. You say that the enrollee advised the services
rendered were eligible for coverage under their plan. You also say that the services were medically necessary.
The Plan denied your request. The Plan says transportation in a wheelchair van is not covered by Medicare or
the Plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport
services.

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided
that the Plan does not have to pay for the non-emergency transportation: wheelchair van (A0130) and
wheelchair van mileage (S0209) provided on May 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that this is medically necessary. The Plan denied your request. The Plan says there is no mention of a diagnosis of cystic fibrosis or the presence of bronchiectasis.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found there is no documentation that the enrollee has cystic fibrosis, bronchiectasis or one of the neuromuscular diseases for
which a high frequency chest wall oscillation device may be covered. The available records do not document that the enrollee presently uses a mechanical in-exsufflation device (E0482) and plans to continue to do so. 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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 6, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that no one informed you that the doctor was not a
participating provider. The Plan denied your request. The Plan says no prior authorization was obtained.

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 office visit provided on August 6, 2021, by an
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the ophthalmology services you had on September 1, 2021.
You asked the Plan to reduce the copayment for the ophthalmology services. You say that your copayment for this service should be $15. The Plan denied your request. The Plan says that you were charged this copayment 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 $15 copayment for Medicare-covered vision care services. The Plan says you must pay a $25 copayment for the ophthalmology services because the services are considered specialist services. Based on the Plan contract however, you cannot be asked to pay more than a $15 copayment for the ophthalmology services. The ophthalmology services you received are Medicare-covered vision care services which have a $15 copayment. Therefore, we decided that the Plan has to reduce the copayment for the ophthalmology services you had on September 1, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on
April 8, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the unlisted molecular pathology procedure. You say that the service was
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the unlisted molecular pathology procedure provided on April 8,
2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on June 22, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the domiciliary visit. You say that the provider relies on facility staff to verify
eligibility and obtain the proper authorization. The Plan denied your request. The Plan says no prior
authorization was obtained.

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 domiciliary visit provided on June 22, 2021,
by an out-of-network (OON) provider.
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 this is medically necessary. The Plan denied your request. The Plan says
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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
respiratory failure, coronavirus (COVID-19) pneumonia, and atrial fibrillation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller
(E2377), and expandable controller harness (E2313).
You asked the Plan to pre-approve an electronic connection, expandable controller, and expandable controller
harness. 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 follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific
criteria are met.
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 an electronic connection, expandable
controller, and expandable controller harness. Our reviewer says that the services are not medically necessary.
Our physician reviewer found based on the medical records provided there is no documentation that you meet
the coverage criteria detailed in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article -
A52504. Records indicate your upper extremity strength is 3/5 to 4-/5 with range of motion within functional
limits. Thus, records indicate you have adequate upper extremity strength and function to operate the
wheelchair's power options with their own switches.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an electronic connection, expandable controller, and expandable controller
harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic
connection (E2311), expandable controller (E2377), and expandable controller harness (E2313).
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 he enrollee needs LTACH services and
cannot get the necessary care at a skilled nursing facility. The Plan denied your request. The Plan says the
criteria for admission to an LTACH are not met. The enrollee can receive the necessary services in a lower
level of care.
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 indicating medical necessity for 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve anterior cervical spine surgery.
You asked the Plan to pre-approve spine surgery services. You say that this procedure is medically necessary
for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have 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 spine surgery services. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is not enough documentation to support the need for anterior cervical spine
surgery. More info is needed to support the clinical indication.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of spine surgery services have not been met. Therefore, we decided that the Plan
does not have to pre-approve anterior cervical spine surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there are no skilled needs and functional goals have been met.
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 the admission. Our reviewer says that
the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no
identifiable skilled nursing service needs. 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 skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion.
You asked the Plan to pre-approve the referral. You say that your medical case is complicated due to chronic
diabetes, high blood pressure, and a 70% blocked kidney. The Plan denied your request. The Plan says the
services can be provided by a plan provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an out-of-network referral for a second opinion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient admission and stay for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is needed because of a lung
infection. The Plan denied your request. The Plan says that this could be done as an observation stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee presented to the Emergency Department on 12/15/2021 with generalized weakness,
as well as fever and myalgias. The vital signs were notable for fever and hypertension. The physical exam was
unremarkable. Laboratory studies were notable for an elevated and rising troponin. The documentation
supports that, at the time of the inpatient admission it was reasonable for the admitting physician to expect that
the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for an inpatient admission and stay 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 pre-approve a power seat elevator, attendant control, expandable controller and cover for a power wheelchair (E2300, K0108, E2311, E2377, E2313, E2331).
You asked the Plan to pre-approve the power wheelchair accessories.. You say that the features are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that power seat elevators are non-covered. Items not primarily medical in nature are not covered. Attendant controllers are not covered when provided in addition to a standard controller. Expandable controllers are only covered when 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 power wheelchair accessories.. Our reviewer says that the requested accessories are not medically necessary. Our physician reviewer found the power seat elevator and cover are primarily non-medical in nature and are not covered. The records show the enrollee is able to use the standard switches to operate the power wheelchair's features, and therefore, the expandable controller is not medically necessary. The attendant control is requested in addition to a patient-operated drive controller and is therefore non-covered. 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 power wheelchair accessories. have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevator, attendant control, expandable controller and cover for a power wheelchair (E2300, K0108, E2311, E2377, E2313, E2331).