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

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on May 6, 2021.

You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for this copayment because it was related to the Coronavirus. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($97.08) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for advanced imaging services (including CT scans).

You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the advanced imaging services benefit category. According to the Plan's Medicare Advantage website, it says that your normal cost shares will apply for treatment of Coronavirus-related symptoms. 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 computed tomography (CT) scan of the chest you had on May 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that pain continues to be high, but she always feels better post-therapy. You say that physical therapy allows her to open up her breathing and alleviate the headaches. The Plan denied your request. The Plan says additional visits are not medically necessary.
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 10 additional physical therapy 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 patient has had prior therapy of at least 29 visits for this condition and has been instructed in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve the Dexcom G6 therapeutic CGM. You say that the enrollee has been hospitalized frequently due to blood sugar in the 20s. The Plan denied your request. The Plan says the enrollee does not receive at least 3 insulin injections per day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. The records show that the enrollee receives one insulin injection per day. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray you had on April 29, 2021.

You asked the Plan to waive the copayment for the x-ray. You say that you should not be responsible for this copayment because it was related to the Coronavirus. 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 $50 copayment for x-rays at an outpatient hospital facility.

You have been asked to pay a $50 copayment for the x-ray. According to the Plan's Medicare Advantage website, it says that your normal cost shares will apply for treatment of Coronavirus-related symptoms. 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 chest x-ray you had on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for phototherapy services you received in a dermatologist's office on May 24, 2021, and May 26, 2021.
You asked the Plan to waive the copayments for the phototherapy services. You say that this should be covered 100% because you were not treated by medical office personnel. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment for medical care in a specialist's office. You have been asked to pay a $40 copayment for the phototherapy services. This copayment applies any time you receive services in a specialist's office, even if no medical personnel are involved. 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 copayments for phototherapy services you received in a dermatologist's office on May 24, 2021, and May 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the chest you had on April 8, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you should not be responsible for this copayment because it was related to the Coronavirus. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($97.08) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for advanced imaging services (including CT scans).
You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the advanced imaging services benefit category. According to the Plan's Medicare Advantage website, it says that your normal cost shares will apply for treatment of Coronavirus-related symptoms. 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 computed tomography (CT) scan of the chest you had on April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal orthotic appliance (D7880).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare or the plan. Therefore, we decided that the Plan does not have to pre-approve an occlusal orthotic appliance (D7880).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pacemaker, dual chamber, rate-responsive (implantable) (CPT code(s): C1785), insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) (CPT code 33225), lead, left ventricular coronary venous system (CPT code C1900), insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular (CPT code 33208), pacemaker, dual chamber, non rate-responsive (CPT code C2619), lead, pacemaker, transvenous vdd single pass (CPT code C1779), and lead, pacemaker, other than transvenous vdd single pass (CPT code C1898), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show the enrollee does not have an ejection fraction of 35% or less.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the 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 that a dual chamber pacemaker and leads are medically reasonable for the enrollee in this case. The enrollee does not have an indication for a dual chamber pacemaker. 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 pacemaker, dual chamber, rate-responsive (implantable) (CPT code(s): C1785), insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system) (CPT code 33225), lead, left ventricular coronary venous system (CPT code C1900), insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular (CPT code 33208), pacemaker, dual chamber, non rate-responsive (CPT code C2619), lead, pacemaker, transvenous vdd single pass (CPT code C1779), and lead, pacemaker, other than transvenous vdd single pass (CPT code C1898), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says coverage criteria have not been met.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 

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 in this case, the record indicates the enrollee has neck and pain from spondylosis.

The record does not state that the pain has been present for more than three months and failed conservative treatment. The record also indicates that the enrollee has radicular symptoms. Therefore the requested service is not considered medically reasonable and 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 not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance service (A0428) and mileage (A0425), provided on March 18, 2021.
You asked the Plan to pay for the non-emergent ambulance service. You say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization is required for non-emergent ambulance services. Medicare rules say that plans may require enrollees to obtain authorization before receiving services. 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 the non-emergent ambulance service. Our reviewer says that Our physician reviewer found 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 non-emergent ambulance service have not been met. Specifically, prior authorization was not obtained for the service. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance service (A0428) and mileage (A0425), provided on March 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you received from March 11, 2021, to March 30, 2021.
You asked the Plan to waive the copayments for the PT services. You say that you were not informed of these copayments. The Plan denied your request. The Plan says you were charged these copayments 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 $40 copayment for physical therapy visits. You have been asked to pay a $40 copayment for the PT services. the PT services falls within the physical therapy visits 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 copayments for physical therapy (PT) services you received from March 11, 2021, to March 30, 2021.
Your complaint about not being told about these copayments beforehand and being enrolled in the wrong plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for the home health services provided on February 17, 2021, through March 18, 2021.

You asked the Plan to pay for the home health services. You say that you would like reconsideration because this claim was billed with the correct dates of service. The Plan denied your request. The Plan says that the Medicare rule for payment of this claim has not been met.

The Plan must follow Medicare rules. Medicare rules say that or continuous care periods, the "through" date must be 29 days after the "From" date for a 30-day period of care. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have been met. Specifically, March 18, 2021 is 29 days after February 17, 2021. Therefore, we decided that the Plan has to pay for the home health services provided on February 17, 2021, through March 18, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation does not support the requested use.
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 Prolia. Our reviewer says that the records do not show that Prolia is medically necessary at this time. Our physician reviewer found the records do not include results from the most recent dual-energy X-ray absorptiometry (DEXA) scan or documentation of previous medical therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery you had at an
outpatient hospital facility on April 23, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you had your first surgery
on April 9, 2021, and it didn't work. You had to have a second surgery on April 23, 2021. You do not think you
should have to pay a copayment for the second surgery. The Plan denied your request. The Plan says you were
charged this copayment correctly because the second surgery was different than the first one.
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 $225
copayment for each outpatient hospital surgery.
You have been asked to pay a $225 copayment for the outpatient surgery. This copayment applies regardless of
the reason for the procedure. 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 surgery you
had at an outpatient hospital facility on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217), provided on March 28, 2021, through April 19, 2021. You asked the Plan to pay for a water circulating heat pad with pump. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a water circulating heat pad with pump have not been met. Therefore, we decided that the Plan does not have to pay for a water circulating heat pad with pump (E0217), provided on March 28, 2021, through April 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can continue to receive appropriate intensive rehabilitation services at the inpatient rehabilitation facility.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services provided on April 26, 2021.

You asked the Plan to waive the copayment for surgical services. You say that you were not charged a copayment last year for the same service. 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 a $10 copayment for surgical services provided in your PCP's office. 

You have been asked to pay a $10 copayment for surgical services. Surgical services fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 surgical services provided on April 26, 2021.