Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to waive the copayment for the paramedic intercept services provided by a fire company on April 7, 2021.
You asked the Plan to waive the copayment for the paramedic intercept services. You say that you already paid a $250 copayment to the fire company that transported you, so you should not have to pay a second copayment for the fire company that only provided the paramedic intercept services. The Plan denied your request. The Plan says you were charged this copayment correctly because the paramedic intercept services are not covered.
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 that enrollees pay a $250 copayment per one-way trip for ambulance services.
In this case, on the date of service in question, an ambulance was requested. Two fire companies showed up. One company physically transported you to the hospital. You have already paid a $250 copayment for that trip. The second fire company only provided paramedic intercept services and did not transport you. The Plan has charged you a second $250 copayment for this service, claiming that the paramedic intercept services aren't covered. The Plan's argument is not supported by the case file documentation they sent to us. According to the claim documentation dated April 30, 2021, the Plan actually paid $189.01 towards the paramedic intercept services, leaving you with a $250 copayment. This does not match with the Plan's argument that the paramedic intercept services are non-covered. The fact that the Plan paid for these services, minus a copayment, seems to indicate that they believed these services were coverable. In addition to that, your Evidence of Coverage is very clear that the $250 copayment is a PER TRIP copayment. You only had one trip, so it is not appropriate for the Plan to charge you a second copayment simply because another provider was involved in your treatment at the scene. Your Evidence of Coverage does not state that you will be responsible for an additional copayment if you receive paramedic intercept services from a second entity. While it is true that Medicare generally doesn't cover paramedic intercept services, that is not what the Plan's claim documentation says- the claim indicates that the service was coverable with the exception of a copayment. This is not appropriate based on the Plan contract. Therefore, we decided that the Plan has to waive the copayment for the paramedic intercept services provided by a fire company on April 7, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6750, D6240).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 dental services (D6750, D6240).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from January 6, 2021, to February 4, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says codes 3HA11, G0162, and Q5001 were not billed with the same date of service and revenue code. The claim is required to have a both the first visit and service location reported with the same date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and date elements. In this case, due to a discrepancy with data elements on the claim, Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from January 6, 2021, to February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the transcutaneous electrical nerve stimulation (TENS) device you received on May 8, 2021.
You asked the Plan to waive the coinsurance for the TENS device. You say that you were advised that this would be covered 100%. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that there are no phone records showing you were provided with incorrect information.
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 durable medical equipment. You have been asked to pay 20% coinsurance for the TENS device. The TENS device falls within the durable medical equipment 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 the transcutaneous electrical nerve stimulation (TENS) device you received on May 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the malignant lesion excision procedure you had at an outpatient hospital facility on May 7, 2021.

You asked the Plan to reduce the copayment for the lesion excision. You say that you were told that your copayment was only $200. 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 $300 copayment for surgery and procedures at an outpatient hospital facility. You have been asked to pay a $300 copayment for the lesion excision. Records show that the facility where you received this procedure is considered an outpatient hospital facility, not an ambulatory surgery center.

That is why the lesion excision falls within the surgery and procedures at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the malignant lesion excision procedure you had at an outpatient hospital facility on May 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on March 2, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound debridement procedures you received at an outpatient hospital facility from March 3, 2021, to March 31, 2021.
You asked the Plan to waive the copayments for the wound debridement procedures. You say that no one ever told you how much this would cost. The Plan denied your request. The Plan says you were charged these copayments 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 $225 copayment per visit for outpatient surgery or procedures at an outpatient hospital facility. You have been asked to pay a $225 copayment per visit for the wound debridement procedures. The wound
debridement procedures fall within the outpatient surgery or procedures at an outpatient hospital facility benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the wound debridement procedures you received at an outpatient hospital facility from March 3, 2021, to March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September 10, 2021 forward.
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 continued inpatient services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 these services. Our reviewer says that the continued inpatient services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on August 21, 2021 with major neurocognitive disorder most likely due to Alzheimer's disease with behavioral disturbance. Based on the records, it is not expected that the enrollee will improve in a reasonable period of time beyond the dates in question, as he is not showing dangerousness to self or others and has no auditory or visual hallucinations. He has no aggressive behaviors and is not showing any acute threats of safety. It does not appear that active treatment is taking place. The enrollee is not showing suicidal or homicidal ideation and is cooperative with care. The continued inpatient psychiatric services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September 10, 2021 forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an astigmatism correcting procedure (A9270).

You asked the Plan to pre-approve the astigmatism correcting procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.

The services you asked the Plan to pre-approve are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pre-approve an astigmatism correcting procedure (A9270).
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 your leg was just amputated, and you need services that the rehab acute level will be able to support and provide. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the care needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for right leg infection and had an above the knee amputation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 could fall if you returned home. You say that your house is not wheelchair accessible and you have no assistance. You say that you only have one leg and need to learn how to do things like walk and shower. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for osteomyelitis and a below the knee amputation. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 1, 2021.
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the items/services at issue in this appeal. 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 out of network physician services provided to the
enrollee on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff needed due to the COVID pandemic for services provided from December 24, 2020, through January 22, 2021, billed with code 99072.

You asked the Plan to pay for the services as billed. You say that this payment should be made due to the added cost of materials during the pandemic. The Plan denied your request. The Plan says this is not a payable code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

The code 99072 has a status indicator of "B" on the Physician Fee Schedule. This means that payment is always bundled in payment for other services provided. As such, no separate payment can be made. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff needed due to the COVID pandemic for services provided from December 24, 2020, through January 22, 2021, billed with code 99072.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for Wellness Allowance benefit
for an exercise program provided on August 1, 2020.

You asked the Plan to reimburse you an additional amount for the Wellness Allowance benefit. The Plan
denied your request. The Plan says that you have been reimbursed the $150 maximum benefit. All costs of
$102 above the allowed $150 remain denied.

The contract with the Plan says that the Plan covers up to $150 each calendar year under the Wellness
Allowance benefit.

We looked at the file and the Plan's rules. The file shows that you have been reimbursed the $150 maximum
benefit. All costs of $102 above the allowed $150 remain denied. Therefore, we decided that the Plan does not
have to reimburse you an additional amount for Wellness Allowance benefit for an exercise program provided
on August 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the mental health care visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the mental health care visit. You say that the in-network providers were not a good fit for you because they do not have experience with bariatric surgery patients. The Plan denied your request. The Plan says the provider is 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 records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the mental health care visit to be provided by an out-of-network (OON) provider.
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 the services are not medically necessary.
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 the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. As a practical matter, the enrollee's care needs can be provided at a lower level of care. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic magnifier.
You asked the Plan to pre-approve an electronic magnifier. You say that you feel this item is medically
necessary. The Plan denied your request. The Plan says the requested item is 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 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 an electronic magnifier.