Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to provide coverage for immunoglobin infusions (IVIG) for the enrollee.
You asked the Plan to provide coverage for immunoglobin infusions (IVIG). You say that this treatment is
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
Maximus overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the
correct coverage criteria and that the review actually states they agree with the Plan.
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of treatment. We
asked our physician reviewer to the case file and apply the relevant Medicare rules to determine coverage. Our
physician reviewer found "there is a lack of definitive evidence in the medical records provided to show the
enrollee is diagnosed with Chronic Inflammatory Demyelinating Polyneuropathy (CDIP)."
The Plan is correct in this case as the medical review states the criteria needed coverage or the diagnosis
needed for coverage are not present. Medicare rules for coverage of this treatment are not met. Therefore, we
decided that the Plan does not have provide coverage for immunoglobin infusions (IVIG)for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from February 5, 2021, to February 12, 2021, and from February 18, 2021, to February 23, 2021.  You asked the Plan to waive the copayment for inpatient hospital services. You say your contention is that the hospital re-admissions are related to the coronavirus (Covid-19) from the first admission of covid pneumonia on November 29, 2020. You also say this fact was not coded nor included in his medical chart, and you believe it to be an oversight. The Plan denied your request. The Plan says you were charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $295 copayment per day for days 1 to 5. The enrollee's contract with the Plan also clearly says that the enrollee's inpatient cost share will begin on day one each time the enrollee is admitted or transferred to a specific facility type, including Inpatient Rehabilitation facilities, Long Term Acute Care (LTAC) facilities, Inpatient Acute Care facilities, and Inpatient Psychiatric facilities  The enrollee has been asked to pay a total of $1,475 in copayments for days 1 to 5 of inpatient hospital services from February 5, 2021, to February 12, 2021 ($295 copayment x 5 days = $1,475). The enrollee has also been asked to pay a total of $1,475 in copayments for days 1 to 5 of inpatient hospital services from February 18, 2021, to February 23, 2021 ($295 copayment x 5 days - $1,475). This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services rendered from February 5, 2021, to February 12, 2021, and from February 18, 2021, to February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable wheelchair ramp (E1399).  You asked the Plan to pre-approve a portable wheelchair ramp. You say that the enrollee needs this item. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose and it 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. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a portable wheelchair ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for IV therapy provided on June 11, 2021.  You asked the Plan to waive the copayment for IV therapy. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   The record shows that you received IV therapy at an outpatient hospital facility on June 11, 2021. Therefore, you are responsible to pay the allowed amount of $218.09, which is less than the $295 copayment.     You have been asked to pay $218.09 for IV therapy. IV therapy falls within the outpatient surgery and other medical 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 IV therapy provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an urgent care visit (99204) rendered on March 31, 2021.  You asked the Plan to waive the copayment for an urgent care visit. You say that you were having symptoms of pneumonia, went to the urgent care where the doctor was insisting it was the coronavirus (Covid19), and then the doctor sent you home without any medication. You also say you were seen a week or two later by your  primary doctor, who verified the pneumonia diagnosis. The Plan denied your request. The Plan says you were charged 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 $45 copayment per visit for covered services to a medical facility or urgent care center.   You have been asked to pay a $45 copayment per visit for an urgent care visit. Urgent care visits fall within the Urgently Needed 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 an urgent care visit (99204) rendered on March 31, 2021.   Your complaint about the provider at the urgent care potentially not listening to your self-diagnosis is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve the right shoulder arthroscopy and surgery.  You asked the Plan to pre-approve the right shoulder arthroscopy and surgery. You say that you would like reconsideration because the requested surgery is medically necessary. The Plan denied your request. The Plan says that without complete information regarding conservative care, the surgery cannot be approved.  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 right shoulder arthroscopy and surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the provided documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. A trial and failure of conservative treatment modalities has been documented.  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 right shoulder arthroscopy and surgery have been met. Therefore, we decided that the Plan has to pre-approve the right shoulder arthroscopy and surgery.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray of lower leg (73590) provided on June 3, 2021.  You asked the Plan to pay for the X-ray of lower leg. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says it is inappropriate to report a procedure both as a global service and as the technical or professional component.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 73590 is not supported in the medical record. Specifically, the record indicates that this service was billed and paid globally on the same date of service. The claim does not include a modifier to indicate that this was a repeat procedure performed by a separate provider. Based on this information, we decided that Medicare rules for coverage of the X-ray of lower leg have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray of lower leg (73590) provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prostate Specific Antigen (PSA) testing provided on January 10, 2020.
You asked the Plan to pay for the PSA testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan follows Medicare rules. Medicare rules say that PSA testing is performed only once per year unless there is a change in the enrollee's medical condition. 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 the PSA testing. Our reviewer says that the documentation does not support that the PSA testing provided was medically reasonable or necessary. Our physician reviewer found the documentation does not include physician progress notes, current PSA level, or prior PSA levels. The documentation does not support that previous PSA's were elevated to make it necessary to do PSAs more frequently than once a year as allowed by the guidelines.
There were no documented diagnoses such as a history of prostate cancer or elevated PSA's to indicate the need for more frequent PSA testing that once a year. Therefore, the enrollee did not meet criteria for the services provided. 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 PSA testing have not been met. Therefore, we decided that the Plan does not have to pay for the Prostate Specific Antigen (PSA) testing provided on January 10, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology service provided on March 18, 2021.  You asked the Plan to pay for lab test. You say that this testing was determined to be medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure code was billed on the same date of service by the outpatient hospital facility so the technical component is included in the payment to the facility.  The Plan must follow Medicare rules. Medicare rules say that payment may be made for the professional component of physician pathology services furnished to hospital inpatient or outpatients by independent laboratories, but payment may not be made for technical component services.    We looked at the file and Medicare rules. The technical component (TC) of this testing was bundled into the payment to the hospital facility where the enrollee was treated; therefore, only the professional component of this testing is payable to the independent lab. However, you did not bill this code using the professional component only modifier. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for pathology service provided on March 18, 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. You say that you need inpatient rehabilitation to regain your strength and recover fully. You cannot get the proper care in another setting. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate 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 based on the documentation provided, the health plan's denial is appropriate in this case. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require or to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met in an alternate 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 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 waive the coinsurance for the ostomy supplies received on February 20, 2020.
You asked the Plan to waive the coinsurance for the ostomy supplies. You say that you disagree with the amount owed. The Plan denied your request. The Plan says the claims have been processed correctly per the enrollee's plan benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for durable medical equipment and related supplies. The enrollee has been asked to pay 20% coinsurance for the ostomy supplies. the ostomy supplies fall within the prosthetic devices and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ostomy supplies received on February 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a wig (A9282).  You asked the Plan to pre-approve a wig. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit.  Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules.  In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig (A9282).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vedolizumab (Entyvio).
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the documentation does not show that the enrollee has had prior therapy, or cannot use Remicade or Inflectra; and Stelara.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Entyvio. Our physician reviewer found that the enrollee was diagnosed with Crohn's disease. It was noted that Humira was tried and failed, Remicade was not provided in the enrollee's area, and Stelara is too expensive. According to the records, none of the required medications were described as having been tried and failed. The required drugs would not likely be less effective or have adverse effects for the enrollee as they all work similarly and have similar effectiveness and risk. Cost of the medication is not considered an indication for bypassing the step therapy requirements. There was no other medical indication to justify this request for Entyvio.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Vedolizumab (Entyvio).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $300 copayment charged to the enrollee for one
ambulance transport provided on March 29, 2020.
You asked the Plan to waive the copayments charged to the enrollee for ambulance transport. You say that you
do not believe these copayments are correct. The Plan denied your request. The Plan says it was determined
that since the enrollee was transferred from one Hospital to the other Hospital to a higher level of care, and the services were not available at the first Hospital, one copayment for the ambulance trip with Ambulance services will be removed. However, the enrollee is still responsible for the $300 ambulance copayment from Ambulance services, as this was an
emergent trip from the home to the hospital.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $300 copayment for each one-way ambulance transport. The enrollee is now being asked to pay the
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $300
copayment charged to the enrollee for one ambulance transport provided on March 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections or waive the copayments for the specialist visits provided to the enrollee from January 29, 2020 to February 25, 2020.
You asked the Plan to waive the coinsurance for the Part B injections and waive the copayments for the specialist visits. The Plan denied your request. The Plan says that the enrollee is responsible for cost sharing.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that the enrollee must pay a 20% coinsurance for Medicare Part B prescription drugs and a $45 copayment for physician specialist services. The enrollee has been asked to pay a 20% coinsurance the Part B injections and a $45 copayment for each of the specialist visits. The Part B injections fall within the Medicare Part B prescription drugs and the specialist visits fall within the physician specialist services benefit category. This means that the enrollee has been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injections and waive the copayments for the specialist visits provided to the enrollee from January 29, 2020 to February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).
You asked the Plan to pre-approve a power scooter. You say that your current cane and walker are not working for you. 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 a power mobility device is covered on when the enrollee's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane, walker, or manual wheelchair. We looked at the file and Medicare rules. The submitted medical records do not indicate whether your mobility limitation can be sufficiently and safely resolved by the use of an appropriately fitted cane, walker, or manual wheelchair. The records indicate you currently use a cane. There is no documentation supporting that this no longer sufficiently and safely resolves your mobility limitation. Based on this information, we decided that Medicare rules for coverage of a power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).