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 you received on September 5, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel as though the bill is wrong. You said that you were not in the hospital for three days, you were only in the emergency room for a few hours. 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 $325 copayment per admission for inpatient hospital services. You have been asked to pay a $325 copayment per admission for the inpatient hospital services. We looked at the medical records from the hospital on this date of service. While you were in the emergency room on this date, the records clearly show that you were admitted as an inpatient from the emergency room. 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 you received on September 5, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive any of coinsurance charged for physical therapy provided
from November 20, 2020, to December 21, 2020.

You asked the Plan to waive coinsurance charged for these services. You say that you would appreciate the
Plans help in waiving this coinsurance as no one told you there would be a charge for each visit. The Plan
denied your request. The Plan says this coinsurance was charged based on the services provided and the Plan
contract agreement. Maximus partially overturned the Plans denial for a lack of documentation in the case file.
The Plan requested a reopen and provided the required documentation.

The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information. Your contract with the Plan clearly says that you must pay 20% coinsurance for each
outpatient physical therapy visit.

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 any of the coinsurance charged for physical therapy provided from November 20, 2020,
to December 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hemodialysis services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the OON dialysis services. You say that the enrollee has used this facility 
since 2014 and does not wish to change. The Plan denied your request. The Plan says there is no medical 
justification to continue at the OON dialysis facility. The services are available from the network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The requested dialysis services are not to 
be provided while out of area. We found no exception that would require the Plan to pre-approve these 
items/services. Therefore, we decided that the Plan does not have to pre-approve hemodialysis services to be 
provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional mileage for routine transportation.
You asked the Plan to provide coverage for additional mileage for routine transportation. The Plan denied your request. The Plan says you have exceeded the benefit.
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.
We looked at your request, the records in the case file, and the rules. The files shows that you have requested coverage for routine transportation from your home to a provider's office that is 99.3 miles, which exceeds the 75 mileage allowed by the Plan. Therefore, we decided that the Plan does not have to provide coverage for additional mileage for routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the chest x-ray and the abdominal ultrasound you had on March 12, 2021.
You asked the Plan to waive the deductible for the x-ray and ultrasound. You say that no one ever told you that there was a deductible. The Plan denied your request. The Plan says you had not met your deductible at the time you received these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to x-ray and outpatient diagnostics. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to x-ray and outpatient diagnostics. This cost sharing is a contractual obligation that had not been met at the time the x-ray and ultrasound was received on March 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the chest x-ray and the abdominal ultrasound you had on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connection (E2311), expandable controller (E2377), and expandable controller harness (E2313).

You asked the Plan to pre-approve electronic connection, expandable controller, and expandable controller harness. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are 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 electronic connection, expandable controller, and expandable controller harness. Our reviewer says that the items are not medically necessary. Our physician reviewer found your strength and function in the upper extremities with the ability to groom yourself supports that you can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of electronic connection, expandable controller, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connection (E2311), expandable controller (E2377), and expandable controller harness (E2313).
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 LTACH services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the enrollee is still receiving acute care services. The enrollee's needs are met in the curing acute setting and the LTACH offers no services that are not currently available to 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 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: 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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you are receiving appropriate care at the present acute care hospital. There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. 
 
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: 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 services are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has 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 the record indicates that the enrollee is not hemodynamically stable and remains 
critically ill. The enrollee continues to receive acute care services, and these have not been denied. The 
enrollee's needs are best met in the current acute care 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 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: Practitioner Services
Decision: Unfavorable


We decided that the Plan does not have to waive the copayment for an outpatient hospital facility visit provided 
on May 27, 2021. 
 
You asked the Plan to waive the copayment for an outpatient hospital facility visit. You say that you disagree 
with the fact that you are paying more than the Plan is. The Plan denied your request. The Plan says the claims 
were processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $475 
copayment for non-surgical visits.  
 
You have been asked to pay the allowed amount of $143.97, which is less than the $475 copayment for an 
outpatient hospital facility visit. An outpatient hospital facility visit 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 an outpatient hospital facility 
visit provided on May 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says 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 the skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's physical function is at or near his baseline and he can receive services 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 the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA).
You asked the Plan to pre-approve the TKA procedure. You say that the enrollee would benefit from this medical necessary procedure. The Plan denied your request. The Plan says the surgery is not shown to be medically necessary.
The Plan follows Medicare rules. Medicare rules say that TKA may be covered when the criteria listed in the Medicare rules section 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 the TKA procedure. Our reviewer says that the documentation does not support that the requested TKA is reasonable and necessary in this case. Our physician reviewer found the enrollee is a female being treated for primary osteoarthritis of both knees. She presented with longstanding bilateral knee pain. This was mostly along the patellofemoral spaces (due to long-standing patellofemoral chondromalacia that is now more into moderately severe patellofemoral arthritic changes.) However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures (including evidence of recent physical therapy with ongoing home exercise program) being utilized. Medication usage, including anti-inflammatories, is not demonstrated on exams. Also, the documentation is not clear on the results from the bilateral knee injections of cortisone on 9/13/21 and/or the Euflexxa injections on 6/2/21. In addition, the MRI is noted on the 10/26/21 exam; however, the formal report was not provided for review. The provided x-rays show "mild generalized bony degenerative change right knee similar to previous exam" while the provider's read of the x-rays are noted to show "patellofemoral arthritic changes, global rimming osteophytes around the patella and also around the femoral sulcus, bone-on-bone contact within the patellofemoral joint". Given the discrepancy of the reads on the x-rays as well as the formal MRI not being provided (as well as the lack of conservative measures being clearly documented), this requested surgery is not fully indicated. 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 TKA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a total knee arthroplasty (TKA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2020.

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 billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 11, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the Velcade injection you received on April 30, 2021.

You asked the Plan to waive the cost sharing for the Velcade injection. You say that you have met your cost share maximum for Medicaid for the month of April. The Plan denied your request. The Plan says you were charged this coinsurance correctly. The Plan says that the $100 administration charge that you were assessed for this date of service has been waived, so the only cost sharing for this date relates to the drug itself. The Plan says that it contacted the hospital on your behalf to see if they had your Medicaid information on file. They advised that they did and they submitted this to Medicaid as well. Medicaid advised that you had not met your share criteria and the hospital stated that you were advised of this several times.

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 chemotherapy drugs. 

You have been asked to pay 20% coinsurance for the Velcade injection. The Velcade injection falls within the chemotherapy 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. You may contact your Medicaid agency if you have questions regarding Medicaid cost sharing amounts. Therefore, we decided that the Plan does not have to waive the cost sharing for the Velcade injection you received on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 23, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 23, 2021.
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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has 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 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. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve Tecentriq. You say that the medication is 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 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 Tecentriq. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Tecentriq is only available to some patients with T2 disease who are Cisplatin (cddp) ineligible. As this enrollee is T1, the requested drug cannot be approved per nccn compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Orthovisc injection you received on November 11, 2020.

You asked the Plan to waive the coinsurance for the Orthovisc injection. You say that you don't believe you owe this amount. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B drugs.

You have been asked to pay 20% coinsurance for the Orthovisc injection. The Orthovisc injection falls within the Medicare Part B 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 the coinsurance for the Orthovisc injection you received on November 11, 2020.