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

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on April 16, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this service should be paid in full because the treatment you received was crucial to stopping your symptoms from progressing. 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 $90 copayment for emergency room services. You have been asked to pay a $90 copayment for the ER visit. 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 emergency room (ER) visit you had on April 16, 2021.
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 LTACH services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for an LTACH are not met. The Plan will continue to cover acute and critical care at the current facility until the enrollee's condition is stable for transfer to a lower level of care or until the clinical circumstances change such that an LTACH may be reconsidered.
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 that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from June 3, 2021, to June 4, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the charges because this treatment was required in order for you to receive a knee surgery. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs from June 3, 2021, to June 4, 2021. The total allowed amount is $10,096.92 and 20% of that is $2,019.38. You have been asked to pay the total coinsurance amount of $2,019.38 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from June 3, 2021, to June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an add metal substructure to acrylic full denture (D5876).
You asked the Plan to pre-approve the add metal substructure to acrylic full denture. You say that you need the plate fixed so you can eat. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 an add metal substructure to acrylic full denture (D5876).
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 IRF care is medically necessary for this enrollee. The
Plan denied your request. The Plan says the criteria for IRF care are not met, and the enrollee can safely receive
the services they need in another 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 that 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. 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: 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 clinical information provided supports the need
for care in an IRF. The Plan denied your request. The Plan says the requirements or coverage of IRF care have
not been met.
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 non-surgical management of a subdural hematoma, nasal bone fracture and two toe fractures
after an assault. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional home PT visits.
You asked the Plan to pre-approve eight (8) additional home PT visits. You say that additional home PT is
medically necessary. The Plan denied your request. The Plan says additional home PT is not medically
necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewereviewer 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 eight (8) additional home PT visits. Our
reviewer says that additional home PT is not medically necessary. 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 and 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 for physical therapy,
by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. 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 eight (8) additional home PT visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve eight (8) additional home PT visits
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 LTACH is the most appropriate level of care for the enrollee. You say that the enrollee requires daily physician monitoring and interventions. You say that the enrollee will benefit from being closely monitored by a nursing staff and therapies that are not available in the short-term acute hospital. You say that the enrollee is medically stable for transfer. The Plan denied your request. The Plan says weaning efforts can continue in the current setting until oxygen requirements are down to a level that can be managed in a lower level of care.
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 the enrollee appears to be receiving appropriate care currently and is improving. He should be appropriate for a lower level of care shortly. Until then, additional care may be provided safely 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. Therefore, this request for LTACH services will be considered not medically necessary as transfer would not provide a significant clinical advantage at this time. Transfer to a lower level of care may be considered when treatment has completed. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the power wheelchair. You say that none of these providers provide a group 3 power wheelchair, so you require the gap. The Plan denied your request. The Plan says there are providers who can provide the Group 2 power wheelchair.
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.
If you require a Group 3 Power Wheelchair, the claim and medical documentation must be submitted for the Group 3 Power Wheelchair for that to be considered. We cannot approve an exception for availability when the appealed code is for a Group 2 Power wheelchair which is available from one of the network providers, even if the Group 3 is not. An out of network exception may be able to be considered for the Group 3 if there are no network options available at that time. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic Device for the enrollee.
You asked the Plan to pre-approve these services. You say that this item is medically necessary for the enrollee. The Plan denied your request. The Plan says that the clinical value and effectiveness of the MyoPro orthotic device in the setting of unilateral right upper extremity impairment following a stroke has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The requested robotic orthosis is not proven to be more beneficial for treatment of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion G Orthotic Device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 26, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the surgery was not able to be completed and you feel that you should not be responsible for the copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per admission for inpatient hospital care. The medical records show that you received inpatient hospital care on May 26, 2021. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment per admission for inpatient hospital care. Inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ostomy supplies you received from March
9, 2021, to March 18, 2021.
You asked the Plan to waive the copayments for the ostomy supplies. You say that you never pay for supplies
and they were always covered 100% before you joined this plan. The Plan denied your request. The Plan says
you were charged these copayments correctly. The Plan says that on dates of service March 10,2021, through
March 18, 2021, the allowed amounts for the supplies you received ($5.38 per date of service) are less than
your copayment obligation, so you are responsible for the full allowed 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 $30
copayment for medical supplies.
You have been asked to pay a $30 copayment for the ostomy supplies. The ostomy supplies fall within the
medical supplies 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 ostomy supplies you received from March 9,
2021, to March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on March 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation mileage.
You asked the Plan to provide additional mileage. You say that you need this transportation approved in order to be able to see this medical provider. The Plan denied your request. The Plan says routine transportation trips must not exceed 50 miles of driving distance. The requested location is more than 50 miles away.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation to Plan-approved locations within 50 miles of driving distance.
We looked at your request, the records in the case file, and the rules. The requested location is more than 50 miles away. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide additional routine transportation mileage.
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 IRF services are medically necessary. The Plan
denied your request. The Plan says coverage criteria has not been met.
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 there is not a reasonable expectation that this patient 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.