Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV).
You asked the Plan to pre-approve a POV. You say that you have limited mobility and that it is critical that you have a mobility chair. The Plan denied your request. The Plan says that there is no documentation that a cane/walker/manual wheelchair cannot meet your needs.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 POV. Our reviewer says that a POV is not medically reasonable and necessary. You have unstable balance, but records do not clearly document that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. There is documentation that your mobility deficit cannot be helped by the use of a walker but there is no documentation that your
mobility deficit cannot be helped by the use of a manual wheelchair. There is no documentation that you can safely operate a power mobility device. Our physician reviewer found that your condition does not meet Medicare criteria for a POV. 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 POV have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you are medically stable and can receive further rehabilitation services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided by
a participating provider on April 21, 2021, to March 6, 2021.

You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that your husband was
never discharged and readmitted. You say that this should be considered one stay. The Plan denied your
request. The Plan says the correct copayments have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $325 copayment per day for days 1-5. There is a $0 copayment for additional days for inpatient
hospital care/in-network.

The enrollee has been asked to pay a $325 copayment per day for days 1-5. There is a $0 copayment for
additional days for an inpatient hospital stay and an inpatient rehabilitation stay. Your 2021 EOC states that
inpatient hospital cost sharing will apply each time you are admitted. This includes when transferring from one
facility to another-or within the same facility between levels of care. The total amount you are being asked to
pay is $1,625 ($350 x 5 days = $1,625 + $0 for additional days). An inpatient rehabilitation stay falls within the
inpatient hospital care/in-network benefit category. This means that the enrollee has been asked to pay the
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for an inpatient hospital stay, and an inpatient rehabilitation stay provided by a participating
provider on February 21, 2021, to March 6, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve a routine transportation trip.

You asked the Plan to pre-approve a routine transportation trip. You say that you require transportation. The Plan denied your request. The Plan says that that your request exceeds the 50 mile limit for transportation.

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 up to 24 one-way routine transportation trips when each one-way trip is less than 50 miles. 

We looked at your request, the records in the case file, and the rules. Our office was able to find a route that is under the 50 mile limit for routine transportation from the pickup address and drop-off address. Based on this information, we decided that the Plan's rules for coverage of routine transportation have been met. Therefore, we decided that the Plan has to pre-approve a routine transportation trip. 

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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided from January 4, 2021, to January 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is services is not payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for these services.

Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99072) provided from January 4, 2021, to January 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).

You asked the Plan to pay for a pneumatic compression device. You say that the device is necessary to prevent deep vein thrombosis. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Claims for E0675 will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675, E0673).
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 enrollee requires IRF care in order to learn to take care of himself after breaking his back. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 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. Medical
problems are stable. There are no complex nursing or rehabilitation needs. 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you had from September 22, 2020, to September 24, 2020.

You asked the Plan to waive the copayment for the ER services. You say that this copayment should be waived because you were admitted. The Plan denied your request. The Plan says you were charged this copayment correctly because you were not admitted as an inpatient.

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 $120 copayment for emergency room visits. This copayment is waived if you are admitted to the hospital within 24 hours.

You have been asked to pay a $120 copayment for the ER services. Records show that you were not admitted to the hospital as an inpatient, rather, you were kept in an observation status which is not an inpatient admission. 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) services you had from September 22, 2020, to September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on October 10, 2020, to October 23, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you had to go here because no one else was qualified to handle your life vest. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $275 copayment per day for days 1-6. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $275 copayment per day for days 1-6. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,650 ($275 x 6 days = $1,650). The correct copayment has been applied to the services that were provided. An inpatient hospital stay 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 an inpatient hospital stay provided by a participating provider on October 10, 2020, to October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May
6, 2021.

You asked the Plan to pay for the dental service. You say that you were advised that the provider was in
network. You also say that you do not understand why this service is not covered. The Plan denied your
request. The Plan says 1 comprehensive exam or periodontic evaluation is covered every 3 calendar years. The
Plan also says that the frequency limit has been exceeded.

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 and comprehensive oral evaluation is
listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a
comprehensive oral evaluation that you received on May 29, 2019, less than 3 years ago. Therefore, we decided
that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for lab services you received from an out-of-network provider on November 12, 2020.

You asked the Plan to waive the coinsurance for the lab services. You say that the pain clinic said they were not going to use your insurance card. You do not know what this bill is for. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You received drug testing lab services from this out-of-network provider.

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 50% of the Medicare-allowed amount for out-of-network lab services.

You have been asked to pay 50% of the Medicare-allowed amount for the lab services. 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 lab services you received from an out-of-network provider on November 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the kidney stone removal procedure you had on April 12, 2021.

You asked the Plan to waive the copayment for the kidney stone removal procedure. You say that the surgery on this date failed because the kidney stones were too large to remove from the front. You then had to have another procedure to have the stones removed from the back. You say that you should not have to pay a copayment for the failed first procedure. 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 for outpatient surgery. 

You have been asked to pay a $250 copayment for the kidney stone removal procedure. The kidney stone removal procedure falls within the outpatient surgery benefit category. This copayment applies regardless of the success of the procedure you have. 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 kidney stone removal procedure you had on April 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on February 8, 2021.

You asked the Plan to pay for psychotherapy services. You say that the provider at issue rendered treatment to the enrollee in good faith. The Plan denied your request. The Plan says that rules for payment have not been met because there is insufficient documentation of consultation, or attempt at a consultation, with the attending or primary care physician.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

In this case, the provided medical records document that the provider of psychotherapy services is sharing information with the attending nurse practitioner. The Plan's denial rationale does not address the records. The Plan has not made reasonable and diligent efforts to gather and forward to us information supporting their decision to deny your request. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on February 8, 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 waive the copayment for CR-39 plastic photochromatic lenses provided on November 10, 2020.

You asked the Plan to waive the copayment for the CR-39 plastic photochromatic lenses. The Plan denied your request. The Plan says the claim processed with the correct copayment applied.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

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 CR-39 plastic photochromatic lenses.

We looked at the file and the Plan's rules. The file shows that the Plan covers CR-39 plastic photochromatic lenses with a $30 copayment. The CR-39 plastic photochromatic lenses falls within the Vison Care, Additional Supplemental Benefits 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 CR-39 plastic photochromatic lenses provided on November 10, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 1, 2020.

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 due to the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first.

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 medical services provided to the enrollee on October 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics purchased March 15, 2021.
You asked the Plan to pay for foot orthotics. You say that you were told orthotics were covered. 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 pay for foot orthotics purchased March 15, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on May 14, 2020.

You asked the Plan to pay for this service. 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 medical services provided to the enrollee on May 14, 2020.