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

We decided that the Plan does not have to pay for air ambulance services provided on November 29, 2020.
You asked the Plan to pay for air ambulance services. You say that air ambulance was medically necessary. The Plan denied your request. The Plan says air ambulance was not medically necessary.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 pay for air ambulance services. Our reviewer says that air ambulance was not medically necessary. Our physician reviewer found that the review indicates that the enrollee reported hearing a popping sound from both lower extremities as she fell while getting up from the toilet. Imaging studies uncovered distal right fibular fracture and fractures of left two metatarsals. The enrollee was anemic with guaiac positive stool, but no obvious signs of gastrointestinal bleeding present during her course in the emergency department. Initial blood pressures of "70s/50s" was resuscitated with 2-liters of fluid. The emergency medical services responders recorded no obvious injuries and moving all extremities. The enrollee was hemodynamically stable. The enrollee was transported by air ambulance from Greely, Colorado to the Medical Center, which was not the closest facility with the necessary services and the initial hospital was equipped for those services. The review has determined that the documentation did support that the enrollee suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation did not support that the enrollee's condition was such that the time needed to transport by ground, or the instability of transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services needed by 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 air ambulance services have been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on November 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam rendered on March 29, 2021.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment 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 $45 copayment for each Medicare-covered hearing exam.

Review of the file shows that you received a hearing exam on March 29, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the Medicare-covered hearing exam 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 diagnostic hearing exam rendered on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging (92133) and the ophthalmological medical examination and evaluation (92012) rendered by the out-of-network (OON) provider on April 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that there were in-network providers available to render the services provided.
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 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 scanning computerized ophthalmic diagnostic imaging (92133) and the ophthalmological medical examination and evaluation (92012) rendered by the out-of-network (OON) provider on April 12, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on May 10, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the copayment. The Plan denied your request. The Plan says the copayment 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 $325 copayment for each Medicare-covered outpatient hospital or ambulatory surgical center visit.
Review of the file shows that you received outpatient surgical services on May 10, 2021. You have been asked to pay a $325 copayment for these services. These services fall within the Medicare-covered outpatient hospital or ambulatory surgical center visit 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 outpatient surgical services rendered on May 10, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services and a coronavirus test on February 22, 2021.

You asked the Plan to pay for the outpatient services. You say that the services were necessary and appropriately rendered. The Plan denied your request. The Plan says the provider has not submitted clinical records that support the medical necessity of the services in dispute.

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 pay for the outpatient services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate the services provided were medically reasonable and necessary for the enrollee in this case. 

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 outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for evaluation and management services and a coronavirus test on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99350) provided on June 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for a home visit. You say that the enrollee could nto choose an in-network provider. The Plan denied your request. The Plan says this was 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 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 a home visit (99350) provided on June 4, 2021 by an out-of-network (OON) provider.
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 these services are medically necessary. The Plan denied your request. The Plan says that the care you require could be provided at an alternate setting, such as skilled nursing facility.

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You have a past medical history of stroke and are living in a long term care facility with ongoing weakness. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the member does not have complex nursing and medical management
needs requiring a resource intensive inpatient hospital 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for nausea, vomiting,
and a urinary tract infection. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The patient 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 an intensive,
multi-disciplinary rehabilitation program. 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. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on April 11, 2021.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 physical therapy provided on April 11, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided on December 29, 2020, to January 9, 2021.

You asked the Plan to pay for inpatient hospital care. You say that at the time you were admitted, you were in hospice. You also say that all services performed while in hospice should be paid in full at no cost to you. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 inpatient hospital care provided on December 29, 2020, to January 9, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive any copayment beyond the first day for the hospital services rendered on May 19, 2021, through May 21, 2021.

You asked the Plan to waive any copayment beyond the first day for the hospital services. You say that you would like reconsideration because you were in the hospital for one day. The Plan denied your request. The Plan says that an inpatient hospital stay was rendered on May 19, 2021, through May 21, 2021.

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.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to forward evidence that you were in the hospital for more than one day. Your specific appeal alleges that you were in the hospital for one day and billed for two. The Plan does not address this claim with necessary documentation. The record also indicates that the rendering facility is in-network with the Plan. It is the burden of the Health Plan to substantiate the denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive any copayment beyond the first day for the hospital services rendered on May 19, 2021, through May 21, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional trips. You say that you require frequent doctor's office visits. The Plan denied your request. The Plan says your benefit only allows 48 trips for this service.

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 a maximum of 48 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used 48 trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva (J0897) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication that the preferred drugs would likely be less effective and/or cause adverse effects.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that the plan's required step therapy drugs have been tried and failed. The documentation does not support that pamidronate or zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva (J0897) 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 20, 2021, to May 25, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you thought it was not considered inpatient if you were released before noon. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $325 copayment per day, for days 1 to 5 for inpatient hospital care. Your contract with the Plan also clearly says that you must pay a $0 copayment per day, for days 6 to discharge.
You have been asked to pay a $325 copayment per day for inpatient hospital care. The records show that you
were inpatient for five (5) days ($325 x 5 days = $1,625). The EOC confirms that inpatient hospital care starts
the day you are formally admitted to the hospital. The day before you are discharged is your last inpatient day.
The EOC also confirms that $325 per day is the required copayment for this service. 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 20, 2021, to May 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox injections. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the enrollee does not have a covered indication for the requested drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Botox injections. Our reviewer says that the requested injections are not medically reasonable and necessary. Our physician reviewer found the enrollee is an 80-year-old male with a diagnosis of a severe flexion contracture of the left upper extremity. Basedon the medical records provided and the guidelines of the Local Coverage Determination (LCD): Chemodenervation (L33458) and the Medicare-approved major drug compendia, there is no documentation that the enrollee has a covered indication for the Botox injections as defined by Medicare criteria. As stated in Micromedex/Drugdex: "OnabotulinumtoxinA has not been shown to improve upper extremity functional abilities, or range of motion at a joint affected by a fixed contracture." The criteria for coverage have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.