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 provided from May 21, 2021, to May 29, 2021.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were advised by a service advocator that you would not be charged due to your coronavirus diagnosis. 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 $295 per day for days 1-4 and $0 per day after day 4 for each inpatient stay. 

The record shows you were in the hospital from May 21, 2021, to May 29, 2021. Therefore, you have been asked to pay $295 per day for the first four days of inpatient hospital services. The total for your stay is $1180 ($295 copayment per day x 4 days = $1180). Please note that as of April 1, 2021, there are no cost-share waivers in effect for coronavirus related treatment. The inpatient hospital services fall within the Inpatient Hospital Care 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 inpatient hospital services provided from May 21, 2021, to May 29, 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 you believe that you need intensive rehab for your leg. The Plan denied your request. The Plan says you are medically stable and do not require frequent physician oversight of your care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is a female who was admitted to the hospital after a fall. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on January 25,
2021.

You asked the Plan to waive the copayment for a breast biopsy. You say that you did not receive anesthesia and
received the procedure in your physician's office. You feel that you should owe $225 and not $325 for this
reason. 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 $325
copayment for outpatient surgery and other medical services and provided at hospital outpatient facilities.

The record shows that you received a breast biopsy at an outpatient hospital facility on January 25, 2021.
Therefore, you are responsible to pay the $325 copayment.

You have been asked to pay a $325 copayment for a breast biopsy. A breast biopsy falls within the outpatient
surgery and other medical services and provided at hospital outpatient facilities and ambulatory surgical centers
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 a breast biopsy provided on
January 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on August 25, 2021.
You asked the Plan to waive the copayment for an EGD. You say that this was a diagnostic procedure and you
have never paid for it in the past. 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 $250
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.
The record shows that you received an EGD at an outpatient hospital facility on August 25, 2021. An EGD is
considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250. You have been asked to pay a $250 copayment for an EGD. An EGD falls within the outpatient surgery and
other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 EGD provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the tanks you have immobilize you from any activity and your quality of life has been taken away. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not been met.
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 home oxygen concentrator with portable tanks. A home oxygen concentrator with portable tanks serves the same purpose as a portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation services (A0429, A0425) provided on July 19, 2021.
You asked the Plan to waive the copayment for the ambulance transportation services. You say that the services should be covered as you were diagnosed with covid-19. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $265 copayment for Ambulance services. You have been asked to pay a $265 copayment for ambulance transportation services. There are no guidelines from the Plan that state an ambulance would be covered if you are diagnosed with covid-19. 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 ambulance transportation services (A0429, A0425) provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on April 1, 2021.

You asked the Plan to pay for the hearing aids. You say that you were not informed that this provider was out-of-
network, and the provider told you that you could be reimbursed for the hearing aids if you paid up front.

The Plan denied your request. The Plan says the provider in this case is not part of the Plan's specified hearing
vendor network. Out-of-network hearing services are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are received from the Plan's hearing vendor network.

We looked at the file and the Plan's rules. These hearing aids were purchased outside of the Plan's specified
network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not
been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on April 1,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device.

You asked the Plan to pre-approve a Vertiflex interspinous and/or interlaminar device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a Vertiflex interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex interspinous and/or interlaminar device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous and/or interlaminar device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for urgently needed services provided on January 18, 2021.
You asked the Plan to waive the copayment for urgently needed services. You say that you were just there as a support person for your husband and did not receive any services. 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 $30 copayment for each visit to a contracted urgent care center and a $40 copayment for each urgently needed visit in a non-contracted urgent care center. The medical records show that you received urgently needed services on January 18, 2021. Therefore, you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 28, 2021.

You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home infusion of Crysvita.

You asked the Plan to pre-approve the home infusion of Crysvita. You say that you would like reconsideration because the requested drug infusion is medically necessary to treat the member's condition and prevent more fractures. The Plan denied your request. The Plan says the requested service is not a Medicare covered benefit.

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 home infusion of Crysvita. Our reviewer says that in order to require Home health care skilled services, the member must be confined to the home, under the care of a physician, and receiving services under a plan of care established and periodically reviewed by a physician. Additionally, the member must be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or have a continuing need for occupational therapy. Being homebound means leaving home is a major effort. Our physician reviewer found in this case, the documentation doesn't support that the member requires in-home skilled nursing services or in-home infusion services to provide treatment that is medically necessary. The documentation doesn't support that the member is homebound. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically necessary as the member can receive services on an outpatient basis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion of Crysvita have not been met. Therefore, we decided that the Plan does not have to pre-approve the home infusion of Crysvita.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve acupuncture services. You say that you have lower back pain and take Tylenol arthritis all day constantly and Ibuprofen. You take cortisone shots which helps your back but not for long. You've considered a chiropractor, but you are scared. 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 acupuncture services 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 pay for injection services provided to the enrollee on July 13, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says authorization was required.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on July 13, 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 SNF 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 does not have any parental medication, complex wound care, or nutrition given via a feeding tube. He is medically stable without any acute exacerbations of chronic medical problems. His 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ameluz.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a previous diagnosis of actinic keratosis and currently has rosacea and a history of skin cancers. The record does not indicate that the requested drug will be used with photodynamic therapy. The medical records provided are insufficient to establish that the requested drug is being used for a medically accepted indication as defined by Medicare rules. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Ameluz.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on May 20, 2021.
You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on May 20, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80048, 84484, 85025), a computed tomographic angiography (70498), contrast material (Q9967), and an electrocardiogram (93005) provided on February 16, 2021.

You asked the Plan to pay for laboratory services, a computed tomographic angiography, contrast material, and an electrocardiogram. You say that these services were provided in good faith. The Plan denied your request. The Plan says these services are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that an Outpatient Prospective Payment System (OPPS) payment status indicator is assigned to every code. The status indicator identifies whether the service described by the code is paid under the OPPS and if so, whether payment is made separately or packaged. 

We looked at the file and Medicare rules. The codes billed for the services at issue have OPPS status indicators that indicate these services are not paid separately as billed. Based on this information, we decided that Medicare rules for coverage of laboratory services, a computed tomographic angiography, contrast material, and an electrocardiogram have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (36415, 80048, 84484, 85025), a computed tomographic angiography (70498), contrast material (Q9967), and an electrocardiogram (93005) provided on February 16, 2021.