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

We decided that the Plan does not have to waive the deductible for lab services you had on April 1, 2021.

You asked the Plan to waive the deductible for the lab services. You say that you are getting a bill for over $200 for these services and if you pay this, you will exceed your deductible. The Plan denied your request. The Plan says this deductible was charged correctly. The Plan says that you did not meet your deductible until after services rendered on April 27, 2021, which was almost a month after the lab services in question. The Plan says that the claim for these lab services was reprocessed and you are only responsible for the deductible amount of $44.15. Since you have now already paid this amount, you have a zero balance for these lab 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 lab services. 

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to lab services. This cost sharing is a contractual obligation that had not been met at the time the lab services were received on April 1, 2021. Therefore, we decided that the Plan does not have to waive the deductible for lab services you had on April 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided from October 27, 2020, to October 30, 2020.
You asked the Plan to pay for the hospital services. You say that these services were medically necessary. The Plan denied your request. The Plan says there is insufficient information to support that these services were provided. Medical records were requested, but only returned for the October 26, 2020 date of service. This date has been paid, but the rest will remain denied.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. No documentation was provided to support the services provided
from October 27, 2020, to October 30, 2020. Based on this information, we decided that Medicare rules for
coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay
for the subsequent hospital care (99232) provided from October 27, 2020, to October 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out-of-network provider at the in-network rate.
You asked the Plan to pre-approve these services. You say that you would like to continue care with this provider. The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the Medicare-allowed amount for an out-of-network specialist visit for Medicare-covered services.
You are requesting services with an out-of-network provider. If you choose to see this provider, you will be asked to pay 50% of the Medicare-allowed amount for these services. These services fall within the an out-of-network specialist visit for Medicare-covered services benefit category. This means that you will be 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. The Plan has network providers from which you may receive
services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve services with an out-of-network provider at the in-network rate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over-bed table.

You asked the Plan to pre-approve the table. You say that this is medically necessary. The Plan denied your request. The Plan says this does not meet the criteria.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an over-bed table.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) services.

You asked the Plan to pre-approve the requested services. You say that BIS assessment is necessary due to the
enrollee's diagnosis. The Plan denied your request. The Plan says that this service is considered experimental
and investigational.

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 the requested services. Our physician
reviewer found that bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid
content as an electric current passes through cell membranes and tissues. Bioimpedance spectroscopy is used
for diagnosis as well as assessing treatment response. BIS is an increasingly utilized diagnostic technique that
allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows
early treatment for prevention of clinically significant lymphedema. This enrollee is at high risk for
lymphedema based on her prior treatment for breast cancer. It has become a standard of care. Therefore, the
service is reasonable and 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 the requested services have been met. Therefore, we decided that the Plan has to
pre-approve bioimpedance spectroscopy (BIS) services.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care to return to previous level of function. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the established patient outpatient office visit (99213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you have been seeing this doctor for many years and would like to continue to see him because you are comfortable with him. He has your anxiety, bipolar and depression under good control. Please reconsider the decision. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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. 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 the established patient outpatient office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network radiation oncologist.

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 available from network providers.

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. 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 a referral to an out-of-network radiation oncologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued inpatient psychiatric admission from February 10, 2021, to February 18, 2021.

You asked the Plan to pay for the continued inpatient psychiatric admission. You say that you did not obtain authorization because the enrollee's record didn't indicate the correct insurance. The Plan denied your request. The Plan says starting February 10, 2021, the enrollee was stable and did not require the intensity of services that could only be provided in an inpatient setting.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 continued inpatient psychiatric admission. Our reviewer says that the inpatient psychiatric admission from February 10, 2021, to February 18, 2021 was not medically reasonable and necessary. Our physician reviewer found that this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided for the admission, this enrollee does not meet the criteria for continued acute inpatient mental health treatment from February 10, 2021, forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative, compliant with treatment while not showing any threats the safety. 

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 continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pay for the continued inpatient psychiatric admission from February 10, 2021, to February 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs provided from April 23, 2021, to April 26, 2021.

You asked the Plan to pay for self-administered drugs. You say that the treatment was necessary, and you were not given any other options. The Plan denied your request. The Plan says self-administered drugs are not a covered service.

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 pay for self-administered drugs provided from April 23, 2021, to April 26, 2021.

Benefits for self-administered drugs 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary level referral to dermatology.

You asked the Plan to pre-approve the referral. You say that this is needed due to a suspicious mole on the back. The Plan denied your request. The Plan says that the submitted notes do not show skin lesions that are suspicious for melanoma.

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 the referral. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found only a board-certified dermatologist can legitimately decide whether the moles are suspicious of melanoma and requiring removal. 

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 referral have been met. Therefore, we decided that the Plan has to pre-approve a tertiary level referral to dermatology.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on August 27, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on August 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of a intra-socket biological dressing (D7922) and general anesthesia (D9222 and D9223).

You asked the Plan to pre-approve the placement of a intra-socket biological dressing and general anesthesia. You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not covered under your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the requested services are not listed in the Plan's supplemental dental benefits chart.

Therefore, we decided that the Plan does not have to pre-approve the placement of a intra-socket biological dressing (D7922) and general anesthesia (D9222 and D9223).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the guidelines for coverage.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial of Retacrit before they will approve the requested Procrit. In this case, the enrollee has not tried and failed the required drug. There is no documentation indicating that Retacrit would likely be less effective and/or likely to have adverse effects 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).
You asked the Plan to pre-approve a power scooter. You say that you need this item. The Plan denied your
request. The Plan says you were given a powered wheelchair on August 8, 2021. The records indicate that you
do not have the upper body and trunk strength to control a scooter or to transfer on and off safely and
independently due to your diagnoses of chronic obstructive pulmonary disease, polyneuropathy, and muscle
weakness. This was confirmed in a phone conversation with your provider who thought that the power
wheelchair that was already given was a much safer option.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have a power wheelchair. a power wheelchair serves the same purpose as a power
scooter. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 23, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the ambulance transport was medically necessary. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the record indicates that the ambulance unit was sent to transport the enrollee to a doctor appointment. The record indicates that the enrollee was in a wheelchair and required stretcher
transportation due to weakness and inability to brace self. The record does not indicate that the enrollee had any active issue or complaint at the time of transportation. The record indicates that the enrollee was hemodynamically normal. The record indicates that no other physical assessment was performed. The rationale for ambulance transportation documented is not credible based upon the record provided. Based upon the record provided, other methods of transportation ae not contraindicated. The elements of the coverage criteria are not satisfied. The requested service is not recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intravenous moderate sedation anesthesia (D9239 and D9243).

You asked the Plan to pre-approve the intravenous moderate sedation anesthesia. You say that the service was medically necessary. The Plan denied your request. The Plan says the requested service is not covered under the member's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Specifically, the requested service is not listed in the Plan's benefit chart. Therefore, we decided that the Plan does not have to pre-approve the intravenous moderate sedation anesthesia (D9239 and D9243).