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

We decided that the Plan does not have to pre-approve Type 2 diabetes remission services from a chiropractor.

You asked the Plan to pre-approve these services. You say that you have diabetes and want to get it under control. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan contract says that up to six supplemental routine chiropractic visits are covered for spinal manipulation. 

The records show that the service at issue is not manual manipulation of the spine. You are requesting a diabetes remission program. These services are not related to spinal manipulation and are not covered by your supplemental chiropractic benefit or your medical benefit. Therefore, we decided that the Plan does not have to pre-approve Type 2 diabetes remission services from a chiropractor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Watchman procedure.
You asked the Plan to pre-approve Watchman procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the documentation does not show that oral anticoagulation is intolerable for coverage through Coverage with Evidence Development (CED) and the Plan would not be responsible for the cost of this procedure under a clinical trial.
The Plan follows Medicare rules. The rules state that percutaneous left atrial appendage closure (LAAC) such as the Watchman procedure may be covered through the Coverage with Evidence Development (CED) program under certain clinical conditions. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 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 Watchman procedure. Our reviewer says that the enrollee does not meet the Medicare criteria for coverage of the Watchman procedure by the Plan. Our physician reviewer found the documentation does not support that the enrollee has been deemed unable to take long-term anticoagulation. We looked at this physician's review, the file, and Medicare rules. The enrollee does not meet the Medicare criteria for coverage of the Watchman procedure through CED. The enrollee may meet the criteria for a clinical trial; however, the Plan would not be responsible for payment of the clinical trial expenses. Based on this information, we decided that Medicare rules for coverage of Watchman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Watchman procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tie down kit for the enrollee.

You asked the Plan to pre-approve a tie down kit. You say that this is necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a tie down kit for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on March 3, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you were told that going back to the emergency room to have the stitches removed would be included in the initial visit. 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 $90 copayment for emergency care. 

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 emergency care provided on March 3, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 9, 2021.

You asked the Plan to waive the copayment for ambulance services. You say that you were transferred late at night after a surgical procedure and had no other form of transportation at that time. 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 $275 copayment for ambulance services. 

You have been asked to pay a $275 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.

You asked the Plan to pre-approve the compression stockings. You say that the services should be covered. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from March 3, 2021, to March 15, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were not adequately educated on what you were signing and would have never agreed to the copayment. 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 days 1-7 for inpatient hospital care. You had an inpatient hospital stay provided from March 3, 2021, to March 15, 2021. Therefore, you are responsible to pay a $225 copayment for days 1-7 (March 3, 2021, to March 9, 2021). $225 (copayment) x 7 (inpatient days) = $1,575. You have been asked to pay the total copayment amount of $1,575 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 provided from March 3, 2021, to March 15, 2021.
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. The Plan denied your request. The Plan says you do not have complex medical management needs or require multiple therapy disciplines.

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 management of an ankle fracture and open wounds of ankle and thigh after a vehicle rolled over the left foot. Your medical problems are stable. You do not require treatment by multiple therapies in 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.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on March 19, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you have had stress tests in the past and never had to pay for the injection. You feel that it should be included in your copayment. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on March 19, 2021. The total allowed amount is $238.16 and 20% of that is $47.64. You have been asked to pay the total coinsurance amount of $47.64 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug injection provided on March 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is no documentation of an active condition that would necessitate a new program.

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 requested services. Our physician reviewer found that in this case, the documentation does not support that you require additional skilled rehabilitation services to provide treatment that is medically necessary. You do not require skilled rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 4, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the medical personnel of the ambulance are able to carry and administer glucose, which is the same thing the emergency room would have done. You also say that you did not need to go to the emergency room. The Plan denied your request. The Plan says your plan covers ambulance transportation only when you are actually transported by ambulance. The Plan also says that since you were not transported by the ambulance, the service is not covered under your plan.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on April 4, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on April 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531.

You asked the Plan to pre-approve the compression stockings. You say that you need this equipment to prevent an ulcer from developing. The Plan denied your request. The Plan says these items not covered when the enrollee does not have an open wound.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related accessory (E0667).
You asked the Plan to pre-approve a pneumatic compression device and related accessory.. You say that this equipment 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 follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related accessory (E0667).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on September 12, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges because you could have driven yourself. 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 $215 copayment for ambulance services. 

You have been asked to pay the allowed amount of $176, which is less than the $215 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee on July 1, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the services was not filed until December 1, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital services provided to the enrollee on July 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 18, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair car lift.

You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair car lift.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on April 13, 2021, and April 14, 2021.


You asked the Plan to pay for the self-administered drugs. You say that you brought all of your medications with you to the hospital, but they were taken away and you were advised that patients cannot self-administer drugs while in the emergency room. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B of Original Medicare.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 pay for the self-administered drugs provided on April 13, 2021, and April 14, 2021.

Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 4, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that you only saw the provider for two minutes and there was no interaction with her. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for each specialist visit for Medicare-covered services.

You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical records show you were seen for a follow-up of Type 1 Diabetes Mellitus. 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 specialist office visit provided on May 4, 2021.