Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from June 6, 2021, to June 9, 2021, and June 10, 2021, to June 16, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you should not be charged two separate copayments. The Plan denied your request. The Plan says you have been charged 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 $360 per day for days 1-5 and $0 per day after day 5 for each inpatient admission. The record shows you were first admitted to the hospital from June 6, 2021, to June 9, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $360 per day for the first three days
of inpatient hospital services, for a total of $1080 ($360 copayment x 3 days = $1080). The record also shows you were admitted a second time from June 10, 2021, to June 16, 2021. Therefore, you have been asked to pay $360 per day for the first five days of inpatient hospital services, for a total of $1800 ($360 copayment x 5 days = $1800). The total for both stays is $2880. Inpatient hospital services 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 services provided from June 6, 2021, to June 9, 2021, and June 10, 2021, to June 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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652, E0667) to be provided by an out-of-network provider.
You asked the Plan to pre-approve a Flexitouch device. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 provider at issue in this case is not a network provider with the Plan. 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 Flexitouch device. Our reviewer says that the requested items are not medically reasonable and necessary in this case. Our physician reviewer found that the provided documentation does not clearly show that the enrollee has tried and failed in-network durable medical equipment (DME)
equivalent options or that the equivalent options would be less effective for the enrollee. 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 Flexitouch device have not been met. 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 a Flexitouch device. Therefore, we decided that the Plan does not have to pre-approve a Flexitouch pneumatic compression device (E0652, E0667) to be provided by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $350 copayment charged for ambulance transport provided on March 29, 2021.
You asked the Plan to waive this copayment. You say that this transport was not authorized, and you should not have to pay this copayment. The Plan denied your request. The Plan says the transport records show you were treated and transported and signed the required release forms to allow the provider to bill your insurance.
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 $350 for each one-way ambulance transport. 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 $350 copayment charged for ambulance transport provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say an SCS trial is covered when specific criteria are met. 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 services are not medically necessary. Our physician reviewer found you had lumbar spinal fusion surgery with continuing low back pain demonstrated by exam and electromyography (EMG) testing. There is no documentation of a psychological evaluation, surgery consultation, physical therapy, or other conservative therapy. The criteria for coverage are not met and the SCS trial is therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 a 49-year-old male with non-healing ulcers of the left foot with calcaneal osteomyelitis and type 1 diabetes and left below the knee amputation. While There are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an ImpediMed L-Dex device.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the use of the requested ImpediMed L-Dex device has been shown to be effective as an alternative method to monitor and/or diagnose lympadema in the medical literature. The services are reasonable and medically necessary for the enrollee at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve an ImpediMed L-Dex device.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiation therapy planning services provided on July 28, 2021.
You asked the Plan to pay for the services provided. You say that a duplicate denial was incorrect. The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The file shows that CPT code 77263 was billed with code 77301 by the same provider for the same date of service. We looked at the file and the rules. We find that CPT code 77263 is not eligible for payment when billed with this code pair. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the radiation therapy planning services provided on July 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT scan of the chest (71250) provided on July 8, 2021.
You asked the Plan to pay for a CT of the chest. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says the request is a duplicate claim that has previously been paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT of the chest have not been met. Specifically, the Plan has documented that it has previously paid for the service at issue. Therefore, we decided that the Plan does not have to pay for a CT scan of the chest (71250) provided on July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization (PAE).
You asked the Plan to pre-approve these services. You say that your BPH has worsened. The Plan denied your request. The Plan says the services are not medically necessary.
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 services are not medically necessary. Our physician reviewer found the records show that you have benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The American Urological Association states that the use of PAE for the routine treatment of BPH is not supported by current data and benefit over risk remains unclear. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization (PAE).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided on July 7, 2021.
You asked the Plan to pay for the hearing aids. You say that the provider scheduled an appointment in January, ordered new hearing aids and were told to submit the claim in the beginning of March. You say that you were not aware of waiting 36 months from the last purchase. The Plan denied your request. The Plan says you have already received the maximum amount of coverage allowed for this type of service.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan only pays for one hearing aid per year every 36 months. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Specifically, the Plan paid for the hearing aids provided on March 20, 2018, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the hearing aids provided on July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam you had on August 30, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that this was just your annual exam, so there should be no charge for 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 $45 copayment for medical eye exams. You have been asked to pay a $45 copayment for the medical eye exam. According to the billing records, this was not a routine eye exam. Rather, this was a medical eye exam to evaluate you for cataracts. That is why the medical eye exam falls within the medical eye exams 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 medical eye exam you had on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a monitoring feature or device, not otherwise classified (A9279) provided on June 6, 2021.
You asked the Plan to pay for a monitoring feature or device. You say that the item at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says the item at issue is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that claims for A9279 are denied as statutorily non-covered. Based on this information, we decided that Medicare rules for coverage of a monitoring feature or device have not been met. Therefore, we decided that the Plan does not have to pay for a monitoring feature or device, not otherwise classified (A9279) provided on June 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are extremely weak and cannot walk. You say that you will not be able to return to normal day to day activities with further physical therapy. You say that you have made some progress but not enough to return home alone. The Plan denied your request. The Plan says the records do not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting.
The Plan says that the enrollee requires custodial care, which is not a covered benefit. The Plan says that intermittent therapy can safely be received at a different setting.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G device.
You asked the Plan to pre-approve MyoPro Motion G device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested device is considered experimental/investigational at this time.
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 MyoPro Motion G device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the MyoPro Motion G device at issue in this case meets Medicare criteria. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MyoPro Motion G device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G device
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 your current medical condition necessitates foot
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device, four or more leads (E0730)
You asked the Plan to pre-approve the TENS device. You say that you would like the Plan to approve the request for a TENS unit and accessories. The Plan denied your request. The Plan says the records did not support that the enrollee meet the reasonable and necessary criteria.
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 the TENS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD excludes chronic low back pain if not enrolled in a clinical trial.
Therefore, the request is deemed not medically reasonable or 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 the TENS device have not been met. Therefore, we decided that the Plan does
not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device, four or more leads (E0730)