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

 We decided that the Plan does not have to waive the copayment for the endoscopy provided on June 17, 2021.  You asked the Plan to waive the copayment for the endoscopy. You say that the Evidence of Coverage clearly stated a $0 copayment for a colonoscopy and the endoscopy should be the same.  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 $200 copayment per visit for Medicare-covered outpatient surgery or procedure at an ambulatory surgical center (ASC).   You have been asked to pay a $200 copayment for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.  This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the endoscopy provided on June 17, 2021.   Your complaint about the benefit design 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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) in home occupational therapy visits (S9129) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve in home occupational therapy visits. You say that you do not want any other nursing facility to care for you. The requested provider has been caring for you since December 6th and you are very comfortable with them. You also say you feel they are the best option for your recovery and if you make any changes to your care, it could be very harmful to you. The Plan denied your request. The Plan says there are in-network providers available for these services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve eight (8) in home occupational therapy visits (S9129) to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies rendered on January 14, 2021 to February 6, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded.  We looked at the file and Medicare rules. Billed proecdure code A0422 (ambulance [als or bls] oxygen and oxygen supplies, life sustaining situation) has a status indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies rendered on January 14, 2021 to February 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the lungs for lung cancer screening.  You asked the Plan to pre-approve the scan. You say that this is not for screening but to check on lung function. The Plan denied your request. The Plan says you haven't smoked in 15 years.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found this scan cannot be approved because you have quit smoking greater than 15 years ago, and you are symptomatic. Thus, the request for procedure code 71271 cannot be approved.  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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve low dose computed tomography (CT) scan of the lungs for lung cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that this item should be covered. The Plan denied your request. The Plan says this is not a covered item.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the assisted living facility (ALF) care provided from December 5, 2020, to January 3, 2021.  You asked the Plan to reimburse you for the ALF care. You say that you were not advised where you would be moving to. You say that you had to take out a loan to pay for these services. You also say that you were not advised why you were being sent home. The Plan denied your request. The Plan says care rendered in an assisted living facility (ALF) is not covered.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ALF care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to reimburse you for the assisted living facility (ALF) care provided from December 5, 2020, to January 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  

You asked the Plan to pre-approve foot orthotics. You say that you had surgery on your feet and now need these orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.  

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 you appear to be more stable at this time and require only additional short-term additional acute care services that can be safely administered at the current facility for the time being. There are no services at the LTACH that you require that are not already available 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy (PT) visits to be rendered by an out-of-network (OON) provider.  You asked the Plan to pre-approve the PT visits. The Plan denied your request. The Plan says no medical need is shown as to why you cannot get these PT visits from a network provider.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy (PT) visits to be rendered by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4) and application of desensitizing medicament (D9910).  You asked the Plan to pre-approve the dental services. You say that the services should be covered. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service. The Plan also says application of desensitizing medicament is not listed as a covered service either.  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 gingival irrigation and application of desensitizing medicament are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921 x 4) and application of desensitizing medicament (D9910).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional epidural steroid injection.  

You asked the Plan to pre-approve an additional epidural steroid injection. You say that this procedure is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the response to the initial injection should be evaluated before another will be approved.  

The Plan must follow Medicare rules. Medicare rules say that a repeat epidural steroid injection will not be covered when performed at the same time as the initial injection.   

We looked at the file and Medicare rules. In this case, the initial injection has been approved. At this time, a repeat injection will only be evaluated after time has passed following the initial injection. Based on this information, we decided that Medicare rules for coverage of an additional epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional epidural steroid injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  

You asked the Plan to pre-approve the compression stockings. You say that the item should be covered. The Plan denied your request. The Plan says this is a non-covered item.  

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 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 A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a walker provided on August 14, 2021.  

You asked the Plan to waive the deductible for the walker. You say that hospital staff informed you that there would be no charge. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $300 deductible which applies to covered services.   

The item or service you asked the Plan to waive the deductible for falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to covered services. This cost sharing is a contractual obligation that had not been met at the time the walker was received on August 14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a walker provided on August 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve genetic testing to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office consultation services (99241) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office consultation services. You say that this care from an OON provider is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to treat your medical condition.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office consultation services (99241) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two (2) office visits with an ophthalmologist (99204, 99214) to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve office visits with an ophthalmologist. You say that you visited an in-network provider on November 15, 2021 and the provider advised that he will not do surgery because of how advanced the cataracts are in both eyes. You also say you have decided to have a second opinion with a different specialist. The Plan denied your request. The Plan says the provider is out of network and the service requested may be provided by a participating provider.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.      

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve two (2) office visits with an ophthalmologist (99204, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for medical services you received from an out-of-network general practitioner from February 2, 2021, to May 4, 2021.  

You asked the Plan to waive the deductible for the out-of-network medical services. You say that you would like to be reimbursed for the money you were charged for out-of-network care. The Plan denied your request. The Plan says you had not met your deductible at the time of these services. Since you had not met your deductible, these charges are not eligible for reimbursement.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to out-of-network services.   

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network medical services were received on February 2, 2021, to May 4, 2021. Therefore, we decided that the Plan does not have to waive the deductible for medical services you received from an out-of-network general practitioner from February 2, 2021, to May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Entyvio (J3380).  You asked the Plan to pre-approve Entyvio. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drugs, 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 reviewer says that Entyvio is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred drugs. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred drugs. Therefore, the reviewer found that the requested drug is not medically necessary as the step therapy criteria has not been met.  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. Specifically, the file shows that the enrollee has not tried and failed the plan's required drugs. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a second unit of procedure code 99232 billed for date of service July 5, 2021.

You asked the Plan to pay for a second unit of procedure code 99232. You say that you have submitted records to support payment. The Plan denied your request. The Plan says it has paid for one unit of procedure code 99232 on this date of service, but medical records do not support payment of a second unit.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We find that a second unit of units of CPT code 99232 are not supported in the medical record. The medical record only supports one unit of CPT code 99232. Therefore, we decided that the Plan does not have to pay for a second unit of procedure code 99232 billed for date of service July 5, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria. 

 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 you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to be able to perform/tolerate fifteen hours per week of rehabilitative services with regular physician evaluation.  Your care needs can be met 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 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.