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

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial.

You asked the Plan to pre-approve a spinal cord stimulator trial. 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 follows Medicare rules. Medicare rules say that no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless specific conditions 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 a spinal cord stimulator trial. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has not an adequate trial of conservative therapy and there is no psychological evaluation. Therefore, the request is deemed not medically reasonable or 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 a spinal cord stimulator trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator trial.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the services are medically necessary due to quality of life. You state have a diagnosis from the physician which includes the necessity of physical, speech, and occupational therapy. The Plan denied your request. The Plan says these services you require are called custodial care and custodial care helps you with daily needs such as dressing, bathing, getting in and out of bed, going to the bathroom, and eating. The Plan states custodial care is not a covered benefit under Medicare or the health plan. The Plan states you do not require daily skilled therapy services, although could possibly benefit from outpatient therapy on an intermittent basis, or treatment under a restorative program.

The Plan states this therapy can safely be received at a different setting, for example, outpatient therapy in residential long-term care.

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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. There is no evidence of an acute decline in function. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received on July 15, 2021.

You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says chiropractic Services are clearly defined and specifically denied in the Evidence of Coverage as covered only under specific conditions.

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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services received on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the acupuncture. You say that you want to see this out-of-network provider because the type of needle helps your pain. The Plan denied your request. The Plan says the provider is out-of-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 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. The records provided for review do not show that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the acupuncture to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device for use in the home.
You asked the Plan to pre-approve a power mobility device. You say that a power mobility device is medically necessary for leg pain. The Plan denied your request. The Plan says the Medicare coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that a power mobility device will not be covered if the patient does not have mobility deficit that impairs their participation in daily activities in the home, or if the patient's condition can be assisted by using a walker, cane, or manual wheelchair. The medical records provided by your physician do not show that you have tried and failed or are not capable of using a cane, walker, or manual wheelchair inside the home. Power mobility devices are not covered for use outside of the home. Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device for use in the home.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transport chair.

You asked the Plan to pre-approve a transport chair. You say that the power wheelchair you have is too heavy to get into a vehicle and this is the only device that I have to get around to the car to the doctor's office. The Plan denied your request. The Plan says Medicare does not cover duplicate equipment or equipment for use outside of the home.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary for use in the home. 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 which technically serves the same purpose as a transport chair.

Medicare does not cover any durable medical equipment for use outside of the home. Therefore, we decided that the Plan does not have to pre-approve a transport chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this service is to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says there are not enough studies to show lumbar interspinous decompression device is safe and effective to treat back pain.

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 surgery. 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 to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction provided on June 21, 2021.

You asked the Plan to pay for the surgical extraction. You say that you were told by the front desk the procedures would cost no money. The Plan denied your request. The Plan says the service is not a covered benefit.

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, surgical extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extraction provided on June 21, 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 based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 

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 waive the copayments for the outpatient procedures to collect blood through a venous port you had at an outpatient hospital facility from April 9, 2021, to June 10, 2021.
You asked the Plan to waive the copayments for the outpatient blood collection procedures. You say that you don't believe there should be a copayment for these services. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for each date of service, the allowed amount ($109.45) is less than your copayment obligation, so you are responsible for the full allowed amount for each.
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 $335 copayment per visit for outpatient surgery or other medical services at an outpatient hospital facility.
You have been asked to pay a $335 copayment per visit for the outpatient blood collection procedures. The outpatient blood collection procedures fall within the outpatient surgery or other medical services at an outpatient hospital facility 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 the outpatient procedures to collect blood through a venous port you had at an outpatient hospital facility from April 9, 2021, to June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the wound care provided from November 4, 2019 to November 26, 2019.
You asked the Plan to waive the copayments for the wound care. You say that you were instructed to go to this facility and these charges should not be billed to you. You say you cannot afford this copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $50 copayment for each visit for Medicare-covered outpatient hospital services. The enrollee has been asked to pay a $50 copayment for the wound care on each date of service. ($50 x 4 visits = $200). The wound care falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the wound care provided from November 4, 2019 to November 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient cataract surgery you had at an outpatient hospital facility on August 3, 2021.

You asked the Plan to reduce the copayment for the outpatient surgery. You say that when you spoke to the facility, they advised they were an ambulatory surgery center and not a hospital. You said you were told the copayment would be $225. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that in order for the $225 copayment to apply, you would have had to have used a free-standing certified ambulatory surgical facility that isn't associated with the hospital.

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 for outpatient surgery at an outpatient hospital facility.

You have been asked to pay a $350 copayment for the outpatient surgery. The Plan has confirmed that the facility where you received these services is considered an outpatient hospital facility. 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 reduce the copayment for the outpatient cataract surgery you had at an outpatient hospital facility on August 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for arthrocentesis and does not have to waive the coinsurance for Medicare Part B drugs provided from June 8, 2021, to June 22, 2021.
You asked the Plan to waive the copayments for arthrocentesis and to waive the coinsurance for Medicare Part B drugs. You say that you are new to the Plan and to Medicare and thought that you would not owe anything for the 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 $40
copayment for specialist visits. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drug. You received arthrocentesis and Medicare Part B drugs at a specialist's office from June 8, 2021, to June 22, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service    Service           Allowed Amount   Amount You Owe
6/8/2021       Arthrocentesis               $90.93               $40
6/8/2021     Medicare Part B Drugs     $705.60           $141.12
6/15/2021     Arthrocentesis               $90.93               $40
6/15/2021    Medicare Part B Drugs    $705.60           $141.12
6/22/2021    Arthrocentesis                $90.93             $40
6/22/2021    Medicare Part B Drugs    $705.60         $141.12

The total amount you owe is: $543.36. You have been asked to pay the total amount of $543.36 for arthrocentesis and Medicare Part B drugs. Arthrocentesis falls within the physician/practitioner services, including doctor's office visits benefit category. Medicare Part B drugs fall within the Medicare Part B prescription drug 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 arthrocentesis and does not have to waive the coinsurance for Medicare Part B drugs provided from June 8, 2021, to June 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis procedure you had at an outpatient hospital facility on July 20, 2021.

You asked the Plan to waive the copayment for the arthrocentesis procedure. You say that you believe this was a claim processing error. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($314.68) 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 $350 copayment for outpatient surgery or other services at an outpatient hospital facility. 

You have been asked to pay a $350 copayment for the arthrocentesis procedure. The arthrocentesis procedure falls within the outpatient surgery or other services at an outpatient hospital facility 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 the arthrocentesis procedure you had at an outpatient hospital facility on July 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the urine capacity tests you received on May 6, 2021, and May 27, 2021.

You asked the Plan to waive the copayments for the urine capacity tests. You say that there should be a $0 copayment for lab services The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that because the allowed amount for each ($9.27) 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 $30 copayment for non-radiological diagnostic services. 

You have been asked to pay a $30 copayment for the urine capacity tests. These urine capacity tests are diagnostic tests, not lab services. 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 the urine capacity tests you received on May 6, 2021, and May 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric surgery.
You asked the Plan to pre-approve the surgery. You say that there have been many unsuccessful attempts to
lose weight. The Plan denied your request. The Plan says there is a lack of medical necessity.
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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found although you have an elevated BMI of 40 kg/m2 and several obesity co-morbid conditions, and may
benefit from bariatric surgery, criteria for eligibility is not determined as there are no dietary efforts
documented in the medical records. Separately, you are noted to have schizoaffective disorder, and although
the criteria does not generally require a behavioral or psychological evaluation, given this history behavioral
clearance would be prudent to obtain, as it is recommended by other national guidelines. It is noted that you
will be meeting with nutrition and behavioral team, but these evaluations were not available for review. Based
on the available information, you do not meet the criteria for this surgery at this time.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve bariatric surgery
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a telehealth visit provided to the enrollee on February 23, 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 the plan did not authorize any services for this provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 a telehealth visit provided to the enrollee on February 23, 2021.