Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for exercise equipment (A9300) purchased on January 12, 2020.
You asked the Plan to reimburse you for exercise equipment. You say that this equipment should be covered
because you were stuck at home and did not have any equipment to keep up with your health. You also say that
you are handicap, and you made the purchase within the time frame. The Plan denied your request. The Plan
says the fitness equipment was purchased before October 1, 2020, is not eligible for reimbursement under the
Plan's health and wellness benefit
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract for 2020
states that the Plan can pay up to $150 per calendar year toward your cost of a membership in a qualified health
club or fitness facility, covered instructional fitness classes, participation in wellness programs, memory fitness
activities, acupuncture and/or nutritional counseling. As of October 1, 2020, and until December 31, 2020, this
benefit may also be used toward the purchase of exercise equipment that you can use at home. Purchases made
prior to October 1, 2020, do not qualify.
The Plan's rules for coverage of gym benefits have not been met because this purchase was made prior to the
Plan's policy changes that became effective on October 1, 2020. Therefore, we decided that the Plan does not
have to reimburse you for exercise equipment (A9300) purchased on January 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve Repatha Sureclick. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has 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 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 Repatha Sureclick.
Benefits for Repatha Sureclick 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified restorative procedure, by report (D2999) provided July 7, 2020.
You asked the Plan to pay for the unspecified restorative procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not covered under Medicare and you do not have supplemental dental benefits.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the unspecified restorative procedure, by report (D2999) provided July 7, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on from September 11, 2020, to September 14, 2020.

You asked the Plan to pay for the laboratory testing. You say that the services are for coronavirus testing which is not related to the enrollee's hospice care. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on from September 11, 2020, to September 14, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
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 step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have left knee osteoarthritis. You have not tried and failed the Plan's required drug, Synvisc/Synvisc-One, Durolane, and Gelsyn-3. The records do not show that the required drugs would be less effective or have adverse effects; therefore, Euflexxa is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from October 22, 2020, to October 25, 2020.

You asked the Plan to waive the copayment for the inpatient care. You say that you feel these services should have been covered as outpatient observation benefits. The Plan denied your request. The Plan says these claims were correctly billed as inpatient services and the appropriate copayment was assessed for these services.

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 $300 copayment for each of the first five days of an inpatient hospital stay. There is a $0 copayment for additional days.

You have been asked to pay a $900 copayment for three days of inpatient care. The services were billed as inpatient services, you were formally admitted as an inpatient, and these were approved by the Plan as medically necessary. 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 inpatient hospital admission and services provided from October 22, 2020, to October 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit, x-rays, assessment and electrical stimulation provided by a chiropractor on May 10, 2021.
You asked the Plan to pay for the spine x-ray (72040), lumbar x-ray (72100), electrical stimulation (G0283), Functional outcome assessment (G8539) and office visit (99213). You say that you are disabled, and the services are a necessity. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit, x-rays, assessment and electrical stimulation provided by a chiropractor on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 12, 2021.
You asked the Plan to pay for lab tests. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation did not include a physician order or intent to order this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order lab services is required for covered lab services. 
We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services on this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment from $281.56 to $40 for the injection(s); single or multiple trigger point(s) (20552) provided on March 9, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 $350 copayment per date of service for outpatient surgery provided at an outpatient hospital facility.

You have been asked to pay a $281.56 copayment for the surgery provided at an outpatient hospital facility.
This is the Plan's allowed amount for this service which is less than the applicable copayment. 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 adjust the copayment from $281.56 to $40 for the injection(s); single or multiple trigger
point(s) (20552) provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating provider on March 2, 2021, to March 26, 2021.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 outpatient hospital services. You have been asked to pay $186.61 which is less than your copayment amount of $225 copayment for outpatient hospital services. The correct copayment has been applied to the services that were provided in an outpatient hospital facility. Outpatient hospital services 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 hospital services provided by a participating provider on March 2, 2021, to March 26, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that you need coverage for additional transportation. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
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 20 one-way trips per year. You have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyewear provided on May 11, 2021.
You asked the Plan to pay an additional amount for the eyewear. The Plan denied your request. The Plan says the claim processed and paid assessing the member responsibility of $802 correctly per the member's 2021 Evidence of Coverage as the annual eyewear allowance of $100 has been paid.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan has paid the maximum eyewear benefit amount of $100, and you are responsible for all costs over the allowance amount. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided on May 11, 2021.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with squamous cell carcinoma in the left upper lobe and underwent a lobectomy, pericardectomy, sacrifice of the left phrenic nerve, and intercostal muscle flap and mediastinal lymph node dissection requiring intubation. He does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that he requires that are not already available and covered at the current facility. The LTACH services are therefore not reasonable or 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement four wheeled scooter for the enrollee.

You asked the Plan to pre-approve a replacement four wheeled scooter. You say that the enrollee requires a replacement scooter because he feels his current scooter is not stable. The Plan denied your request. The Plan says the current scooter is less than 5 years old and not permanently damaged, or permanently worn due to daily usage. Therefore, this request will not be covered by insurance.

The Plan must follow Medicare rules. Medicare will not replace current equipment less than five years old for upgraded equipment. The current equipment does not appear to need repair or replacement. Medicare does not replace or grant new equipment for convenience or for safer use outside of the home. Therefore, we decided that the Plan does not have to pre-approve a replacement four wheeled scooter for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network prosthesis and services.

You asked the Plan to pre-approve out of network providers and out of network prosthetics. You say that you prefer to use the requested provider. The Plan denied your request. The Plan says this provider is not in network.

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 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. Therefore, we decided that the Plan does not have to pre-approve an out-of-network prosthesis and services from this Provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and hospital services provided from March 24, 2021, to March 31, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 copayment for each of the first 8 days of an inpatient hospital stay, a $113 copayment for a 9th day, and a $0 copayment per day for days 10 and beyond. There is a $1,913 out-of-pocket limit per stay.
You have been asked to pay a $1,575 copayment for the 7-day inpatient stay. There is a $225 copayment for each of the first 8 days of an inpatient hospital admission. ($225 x 7 = $1,575). 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 inpatient admission and hospital services provided from March 24, 2021, to March 31, 2021.
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 services are 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 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's physical function was at or near his baseline and he could have received further services at a lower level of care. Admission to the nursing facility at a skilled level of care for inpatient skilled services was not 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by
Medicare.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The Vertiflex device
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that your
condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex Superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.

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 not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair is 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the records show that you have a history of diabetes, lumbar disc disease, fibromyalgia, and chronic pain syndrome. There is no documentation that you have a personal mobility deficit that impairs participating in mobility-related activities of daily living (MRADLs) in the home that cannot be helped by the use of a walker or cane. The criteria for coverage are not met and the manual wheelchair is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 14, 2020.
You asked the Plan to pay for the services provided. You say that medical records support the billed services.
The Plan denied your request. The Plan says the records submitted were for a different enrollee.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the
documentation in the beneficiary's medical documentation.
We looked at the file and the rules. We find that the billed services are not supported in the medical record.
Specifically, there are no records provided to show the services were rendered. The records show that the Plan
requested additional information on multiple occasions with no success. Based on this information, we decided
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay
for the lab services provided on October 14, 2020.