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

We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim has not been processed by the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that an Explanation of Benefits (EOB) has not been received from the primary insurer. As the secondary
insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the continuous glucose monitor sensor (A9276) provided on March 24, 2021. We decided that the Plan does not have to waive the coinsurance for the insulin pump (A4224) provided.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan says that the coinsurance has been applied correctly to the items provided.
We decided that the Plan has to waive the coinsurance for the continuous glucose monitor sensor (A9276) provided on March 24, 2021. The Plan contract states that enrollees pay a $0 copayment for Medicare-covered diabetic supplies. Therefore, we decided that the Plan has to waive the coinsurance applied for the continuous glucose monitor sensor (A9276) provided on March 24, 2021.
We also decided that the Plan does not have to waive the coinsurance for the insulin pump (A4224) provided on March 24, 2021. The insulin pump provided in this case is classified as durable medical equipment. Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered durable medical equipment with a total rental or purchase price of $500 or more of the Medicare allowable rate per item per month. The Medicare allowable amount for this item was $594.90. The cost sharing applied was the Medicare allowable amount of $594.90 x 20% coinsurance= $118.98. Therefore, we decided that the Plan does not have to waive the coinsurance applied for the insulin pump (A4224) provided on
March 24, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN)
(G0299).
You asked the Plan to pre-approve the direct skilled nursing services of a RN. The Plan denied your request.
The Plan says skilled nursing services for monitoring the enrollee's blood pressure and administration of
Trulicity are not required to effectively provide treatment, care, and/or services which are medically necessary
for the enrollee beyond what has been approved by the Plan.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician 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 direct skilled nursing services of a
RN. Our reviewer says that the requested, ongoing, home health skilled nursing services are not medically
necessary or reasonable. Our physician reviewer found the enrollee does not have documented skilled nursing
needs.
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 direct skilled nursing services of a RN have not been met. Therefore, we
decided that the Plan does not have to pre-approve direct skilled nursing services of a registered nurse (RN)
(G0299).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for he annual wellness visit rendered on September 30, 2021.
You asked the Plan to pay for these services. You say that this was the only time you saw the doctor this year.
The Plan denied your request. The Plan says the benefit limit is exhausted.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an annual
wellness visit (AWV) once every 12 months.
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
The file shows that you previously had an AWV on May 11, 2021 that was covered by the Plan. Therefore, we
decided that the Plan does not have to pay for he annual wellness visit rendered on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the meningococcal conjugate vaccine provided to you on September 29, 2021.

You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the meningococcal conjugate vaccine provided to you on September 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy (CPT code G0151 x4) and home health skilled nursing services (CPT code G0299 x3), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician 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 physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs, as no skilled nursing notes were provided. The enrollee does not have documented skilled therapy needs, as the enrollee is functioning with stand-by assistance. As such, the requested quantity of home health services is not shown to be medically necessary or reasonable. 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 home health physical therapy (CPT code G0151 x4) and home health skilled nursing services (CPT code G0299 x3), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive coinsurance for an injection provided on November 19, 2020.
You asked the Plan to waive coinsurance for an injection. You say that the injection should be covered by the
Plan at 100%. 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 20%
coinsurance for Part B drugs.
You have been asked to pay $71.23, which is 20% of the allowed amount for an injection ($356.16 allowed
amount x 20% = $71.23). An injection falls within the Medicare Part B Prescription Drugs benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive coinsurance for an injection provided on November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Nuedexta capsule.

You asked the Plan to pre-approve Nuedexta. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Nuedexta capsule.

Benefits for Nuedexta may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 correct level of care for the enrollee
is a LTACH. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been
met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that there is no documentation provided indicating medical necessity for admission to
an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.

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 the enrollee does not have documented skilled nursing needs or documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tudorza for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tudorza for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that your spouse and you are
unable to drive. You also say the enrollee is currently being required to attend physical therapy visits between
February 28, 2022 and April 1, 2022. The Plan denied your request. The Plan says the enrollee has exhausted
the maximum benefit of 24 one-way trips per year.
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 24 trips per year.
We looked at your request, the records in the case file, and the rules. The records shows that the enrollee has
used 24 one-way transportation trips this year. Based on this information, we decided that the enrollee has
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 trips.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty-two (22) additional physical therapy (PT) visits
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not
meet criteria.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the enrollee has had prior PT of 10 outpatient visits. The enrollee has
been authorized 2 more sessions of PT to be instructed in a home exercise program. The enrollee does not have
significant functional deficits that require additional PT beyond what was already approved. The requested
services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a
qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve twenty-two (22) additional physical therapy (PT) visits
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. The Plan denied your request. The Plan says the enrollee does not
need an interdisciplinary team approach to rehabilitation care.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for respiratory failure and coronavirus pneumonia. 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.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus testing rendered on September 1, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. The Plan states that only one COVID-19/Coronavirus test is covered per day. We looked at the file and Medicare rules. The file shows that the Coronavirus testing was billed with diagnosis code N18.6 for end-stage renal disease (ESRD). Under Medicare rules, payment for these services is included in the ESRD payment. However, the Plan covers one Coronavirus test per day. One test was paid. The second
test is not covered per the Plan rules. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing rendered on September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery you had at an outpatient
hospital facility on June 30, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that this surgery was only to
replace the battery in your current stimulator and you have never had a high out-of-pocket cost for this. You
believe you were overcharged. The Plan denied your request. The Plan says it has reprocessed this claim and
you now only owe the $290 copayment for the surgery.
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 $290
copayment for outpatient hospital services.
You have been asked to pay a $290 copayment for the outpatient surgery. The outpatient surgery falls within
the outpatient hospital 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
outpatient surgery you had at an outpatient hospital facility on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you to be discharged from hospital into an acute care
rehabilitation facility. The Plan denied your request. The Plan says the stay is not medically necessary based on
IRF criteria. The Plan states you could receive care in another setting and the plan could review alternate
settings if requested such as a skilled nursing facility, outpatient setting or home health care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
respiratory failure and Coronavirus (COVID-19) pneumonia. 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an
intensive 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.
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 IRF admission and services.