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

We decided that the Plan does not have to waive the copayment for the upper gastrointestinal (GI) endoscopy with biopsy you had at an ambulatory surgery center on August 3, 2021.

You asked the Plan to waive the copayment for the upper GI endoscopy. You say that this service is an important part of preventive care to avoid the costs of colon cancer. Because this is preventive, there should be no copayment. You stated that this copayment is a financial hardship for you. The Plan denied your request. The Plan says the copayment for this date of service applies to the endoscopy you had, not to the colonoscopy you had at the same time. The Plan says that this copayment was charged 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 $250 copayment for outpatient surgery.

You have been asked to pay a $250 copayment for the upper GI endoscopy. The upper GI endoscopy falls within the outpatient surgery benefit category. There is no provision in your contract for a waiver of this amount, regardless of whether or not the upper GI endoscopy is preventive in nature. 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 upper gastrointestinal (GI) endoscopy with biopsy you had at an ambulatory surgery center on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a teletypewriter (TTY) device.  You asked the Plan to pre-approve a TTY device. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a TTY device is not covered by Medicare or the Plan.  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 teletypewriter (TTY) device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the bone scan and the computed tomography (CT) scan of the abdomen and pelvis you had on September 7, 2021.

You asked the Plan to waive the copayments for the bone scan and the CT scan. You say that you did not know you would be charged two copayments for the same date of service. You stated that this is a financial hardship. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for the CT scan ($202.86) is less than your copayment obligation, you are responsible for the full allowed amount for that service.

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 $300 copayment for each for diagnostic imaging service.

You have been asked to pay a $300 copayment each for the bone scan and the CT scan. The bone scan and the CT scan fall within the diagnostic imaging service benefit category. Your contract explicitly states that you are responsible for this copayment for each individual service. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the bone scan and the computed tomography (CT) scan of the abdomen and pelvis you had on September 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from October 11, 2021, to October 13, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel as though this copayment is too high considering that you also pay a monthly premium. 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 $360 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for two days. You were charged a $360 copayment for each day, for a total of $720. 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 inpatient hospital services you received from October 11, 2021, to October 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier, provided on December 24, 2020.  You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier. The Plan denied your request. The Plan says because the member was not actually transported by ambulance, this expense is not covered by the member's benefit plan.  The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with a QL modifier, provided on December 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2750).  You asked the Plan to pre-approve the crown. You say that there is no decay and no infection on the tooth. You also say that there is no reason for this service to be denied. The Plan denied your request. The Plan says this service is not covered.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided from July 6, 2021, to July 9, 2021.  You asked the Plan to waive the copayment for an emergency room visit. You say that you believe you were admitted as an inpatient and that your copayment should be waived. The Plan denied your request. The Plan says the medical records and claim both indicate you were in the hospital under observation status. The Plan states the cost-sharing was applied 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 $100 copayment for each Medicare-covered emergency room visit.   You have been asked to pay a $100 copayment for an emergency room visit which 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 an emergency room visit provided from July 6, 2021, to July 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from July 30, 2021, through August 2, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that an inpatient admission was not medically necessary.

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 that the review indicates that the record showed that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency deparment 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 the acute inpatient hospital care provided from July 30, 2021, through August 2, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve iTIND (Temporarily Implanted Nitinol Device) procedure.

You asked the Plan to pre-approve iTIND procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

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 iTIND procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has benign prostatic hyperplasia (BPH) and lower urinary tract symptoms with American Urological Association (AUA) score of 20. The enrollee could not tolerate tamsulosin and terazosin due to dizziness. 5-alpha reductase inhibitors were not effective. Prostate volume is 15 gm. Maximum flow rate is 9.8 cc/s. There is scarce data in the published peer-reviewed scientific evidence to determine the safety and efficacy of the iTIND as a treatment option for BPH. The American Urological Association (AUA) guideline summary for effective evidence based surgical management of males with lower urinary tract symptoms due to BPH does not include iTind. Therefore, the enrollee does not meet criteria for the requested services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of iTIND procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve iTIND (Temporarily Implanted Nitinol Device) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), mandibular partial denture (D5214), and four extractions (D7210 x4).

You asked the Plan to pre-approve the partial dentures and extractions. You say that you need four extractions and two partials. The Plan denied your request. The Plan says partial dentures are not covered. The Plan also says that your extraction benefit has been exhausted for the 2021 plan year.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary partial denture (D5213) and mandibular partial denture (D5214) are not among those covered under this benefit. The contract says that you are limited to 1 simple extraction per year. The record shows that you were approved for one extraction (D7210) on November 22, 2021 and your extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), mandibular partial denture (D5214), and four extractions (D7210 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you would like to explore other treatment options due to poor outcomes with the current provider. The Plan denied your request. The Plan says the physician and the facility are out-of-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The record shows the provider, and the facility are out-of-network. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.

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 based on the documentation provided the enrollee only requires short-term additional
acute care services that can safely be administered at the current facility. The enrollee does not require services
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor.

You asked the Plan to pre-approve a FreeStyle Libre 14 Day Sensor. You say that you need this item. The Plan denied your request. The Plan says you do not meet the criteria for this item.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre 14 Day Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 14 Day Sensor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transfer bench (E0247).  You asked the Plan to pre-approve a transfer bench. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a transfer bench is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.   While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a transfer bench (E0247).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional PT visits.  You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy per documentation but there are no objective therapy notes or objective treating medical provider notes with detailed outcomes of prior therapy or deficits that require ongoing formal skilled PT. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four interim implant abutment placements (D6051 x4).

You asked the Plan to pre-approve the interim implant abutment placements. You say that you need this procedure as soon as possible and would like it to be covered by the Plan. The Plan denied your request. The Plan says this service is not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve four interim implant abutment placements (D6051 x4).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a conversion kit and non-standard color options for a group four power wheelchair.

You asked the Plan to pre-approve a conversion kit and non-standard color options for a power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 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 conversion kit and non-standard color options for a group four power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve denosumab (Prolia).  You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not have a history of an osteoporotic fracture, or a contraindication to zoledronic acid.   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 Prolia. Our physician reviewer found that the enrollee has age-related osteoporosis without current pathological fracture. The Plan requires a history of an osteoporotic fracture, or a contraindication to zoledronic acid. before they will approve the requested drug. The case file does not contain documentation of a history of an osteoporotic fracture, or a contraindication to zoledronic acid. The documentation does not support that zoledronic acid would likely be less effective or would likely have adverse effects for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve denosumab (Prolia).