Persius/hicric huggingface dataset:
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 the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the robotic arm (L8702).
You asked the Plan to pre-approve the robotic arm. You say that the enrollee has exhausted all other available
therapies and has not regained meaningful use of her left upper extremity. The Plan denied your request. The
Plan says this item is considered experimental and investigational. There is insufficient evidence of its
effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the robotic arm have not been met. Therefore, we decided that the Plan does not have to preapprove
the robotic arm (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 22, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 the drug testing provided on October 22, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 1, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that the doctor did not complete a surgical procedure and now you will have to pay again on top of outpatient hospital costs. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on March 1, 2021.
We note your complaint that the doctor did not complete a surgical procedure. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the abdomen you received on April 22, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you were told there was no copayment for this service. 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 $195 copayment for diagnostic and nuclear medicine radiology services. 

You have been asked to pay a $195 copayment for the MRI. The MRI falls within the diagnostic and nuclear medicine radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the abdomen you received on April 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 6, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cardiac catheterization procedure you had on April 12, 2021, and the diagnostic testing services you received on April 15, 2021.
You asked the Plan to waive the cost sharing for the cardiac catheterization procedure and diagnostic testing services. You say that your copayment for heart surgery should encompass all of the other related services. You said that your copayment should be limited to the $200 copayment for the surgery itself. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that you had your original heart surgery from March 31, 2021, to April 2, 2021. You then returned to the hospital on April 12, 2021, for a cardiac catheterization procedure. You returned once more on April 15, 2021, and received numerous diagnostic tests including lab services, a chest x-ray, and pulmonary function testing. These are separate services for which 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 $250 copayment for outpatient surgery and services in an outpatient hospital facility and 20% coinsurance for diagnostic procedures and tests. You have been asked to pay a $250 copayment for the cardiac catheterization procedure and 20% coinsurance for the diagnostic testing services. Your Plan is permitted to charge separate cost sharing for these services since they did not occur at the same time and during the same admission as the original heart surgery. 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 cost sharing for the cardiac catheterization procedure you had on April 12, 2021, and the diagnostic testing services you received on April 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on September 30, 2020.
You asked the Plan to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888). The Plan denied your request. The Plan says emergency medical services reported that the patient was requesting to go be transported to be evaluated at the clinic for diarrhea and diverticulitis, bypassing the nearest hospital from which she was recently sent home.
The Plan must follow Medicare rules. Medicare rules say that Medicare only covers ambulance transportation to the nearest appropriate facility.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional ambulance mileage (A0888) have not been met. Specifically, the record shows that the enrollee received transportation services beyond the nearest appropriate facility. This means that the additional ambulance mileage is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on September 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from February 15, 2021, to March 4, 2021.

You asked the Plan to waive the copayment for the SNF services. You say that you don't agree with the dates that you were in the facility and you do not believe you should have to pay this. 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 $0 copayment for days 1-20, and a $160 copayment for days 21-44 per benefit period for skilled nursing facility services.

Your medical records confirm that you were in a SNF from January 6, 2021, to January 25, 2021, for a total of 19 days. You were not charged a copayment for this stay. You were then admitted to another SNF from February 15, 2021, to March 4, 2021, for a total of 17 days. You were charged a $160 copayment per day for the last 16 days of this stay (for a total of $2,560), since there is no copayment for days 1-20 for SNF services (and you already had 19 days' worth of SNF services at the previous SNF.) 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 skilled nursing facility (SNF) services you received from February 15, 2021, to March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that you are scared of pricking your finger for testing. The Plan denied your request. The Plan says you are not being treated with insulin therefore the coverage criteria for the CGM is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services provided on April 12, 2021.
You asked the Plan to waive the copayment for chiropractic services. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for chiropractic services. You have been asked to pay a $20 copayment for chiropractic services. Chiropractic services fall within the chiropractic services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for chiropractic services provided on April 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on March 1, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you were unconscious and did not choose to go to an out-of-network hospital. You stated that you are only supposed to pay $90 for emergency transportation. 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 $250 copayment per trip for ambulance services. You have been asked to pay a $250 copayment per trip for the ambulance services. This copayment applies to both emergency and non-emergency ambulance transport. The $90 copayment that you cite in your appeal letter is for Emergency Room services or Emergency Room and ambulance services outside of the country. Neither one of those scenarios applies here. 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 ambulance services you received on March 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 17, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you were assaulted and cannot afford the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 copayment for ambulance services. 

You have been asked to pay a $265 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on August 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch intermittent limb compression device to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the compression device. You say that although you are not on contract with the Plan, you accept the Plan and Medicare's in network payment rate for the device. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the Flexitouch intermittent limb compression device to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a capsule endoscopy (91110).
You asked the Plan to pre-approve a capsule endoscopy. You say that please review the attached clinicals to
support medical necessity for capsule endoscopy. The Plan denied your request. The Plan says the medical
information provided does not support medical necessity. The enrollee does not meet medical criteria for
coverage.
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 a capsule endoscopy. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found per the provider's appeal letter of August 20, 2021, the enrollee has not undergone a
recent upper endoscopy nor a colonoscopy, and therefore, does not meet coverage criteria for the proposed
repeat capsule endoscopy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a capsule endoscopy have not been met. Therefore, we decided that the Plan
does not have to pre-approve a capsule endoscopy (91110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on July 14, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested 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 the physician services provided on July 14, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 16, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you are requesting for the claim to be paid. You say these claims have always been paid even though the provider is out-of-network. The Plan denied your request. The Plan says no prior authorization was obtained.

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 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 16, 2020 by an out-of-network (OON) provider.