Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you are in constant pain and your doctor
has tried everything they could. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because the Plan has approved 2 level of facet joint injections but there is no medical need
for a third.
The Plan follows Medicare rules. Medicare rules state that the need for a 3 or 4 level facet joint intervention
procedure may be considered under unique circumstances with sufficient documentation of medical necessity.
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 facet joint injections. Our reviewer says
that you do not meet the Medicare criteria for a third level of facet joint injections. Our physician reviewer
found it is not medically necessary and reasonable for you to have these lumbar facet injections as an exception
to the rules.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve a third level of facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective lens coating and miscellaneous vision service provided on March 17, 2021.
You asked the Plan to pay for the anti-reflective lens coating and miscellaneous vision service. You say that there is $100 allowance every 24 months for eyewear that should be covered up to the maximum allowance every two years. You say that you believe you qualify for the $100 allowance. The Plan denied your request. The Plan says the services are not covered benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The anti-reflective lens coating and miscellaneous vision service is not covered by the $100 allowance. We looked at the file and the Plan's rules. The $100 allowance only applies to frames and lenses. The Plan applied $89.95 toward the $100 allowance for the cost of the frames. Based on this information, we decided that the Plan's rules for coverage of the anti-reflective lens coating and miscellaneous vision service have not been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective lens coating and miscellaneous vision service provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit on April 16, 2021.

You asked the Plan to waive the copayment for the specialist office visit. You say that this was a post-op visit from a surgery so you shouldn't be charged. The Plan denied your request. The Plan says this visit was beyond the 90-day global period.

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 $35 for Physician Services. 

You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the Physician Services benefit category. The surgery had a 90-day global surgery period from December 30, 2020. 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 specialist office visit on April 16, 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 for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.
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 considered medically reasonable and necessary in this case. There is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6212).

You asked the Plan to pre-approve the foam dressing. You say that you are appealing he denial of the special pads with adhesive for your back wound. You would most likely be sent without adhesive but the area of the back you need the adhesive for is necessary to stay on. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested service.

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 foam dressing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided documentation, the enrollee's wounds were not stage 3 or 4 and did not support use of foam dressing on a regular basis. Therefore, coverage criteria were not met by the enrollee's conditions for these dressings. 

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 foam dressing have not been met. Therefore, we decided that the Plan does not have to pre-approve the foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing (A6212).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 28, 2020.
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 Medicare denies coverage for all cardiovascular risk assessment testing/panels.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no benefit for screening cardiovascular risk assessment for asymptomatic patients. Screening asymptomatic patients for cardiovascular risk is statutorily excluded by Medicare.
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 pay for laboratory services provided to the enrollee on September 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laminectomy services (63005) provided on February 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the laminectomy services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 the laminectomy services (63005) provided on
February 25, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on February 5,
2021, from an out-of-network provider.
You asked the Plan to pay for the digital hearing aids. You say that you should be reimbursed the $1,000
allowance for these necessary hearing aids. The Plan denied your request. The Plan says hearing aids purchased
outside of the specified hearing provider network 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 up to
$1,000 for hearing aids every three years only when they are purchased from a provider in the Plan's specified
hearing vendor network.
We looked at the file and the Plan's rules. These hearing aids were not purchased from a provider in the Plan's
specified network. Based on this information, we decided that the Plan's rules for coverage of the digital
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the digital hearing
aids (V5261) purchased on February 5, 2021, from an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial services provided May 22, 2020, to June 2, 2020.
You asked the Plan to pay for the custodial services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says custodial care is not a covered benefit.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the custodial services provided May 22, 2020, to June 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received February 10, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan should waive the copayment due to errors made by the hospital. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 they must pay a $225 copayment for Ambulance Services. 

The enrollee has been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when they enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on January 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these
services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on January 11, 2021.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the respiratory assist device provided on November 27, 2020.

You asked the Plan to waive the cost share for the provided item. You say that you have life-threatening breathing issues. The Plan denied your request. The Plan says the claim will be reprocessed with a cost share.

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 20% coinsurance for durable medical equipment.

The file shows that the Plan has agreed to reprocess the claim and approve the respiratory assist device. You have been asked to pay a 20% coinsurance for the device. The service falls within the durable medical equipment benefit category. Sales tax is not payable or reimbursable. 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 cost share for the respiratory assist device provided on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the limited oral evaluation - problem focused (D0140), the panoramic radiographic image (D0330), and the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) received March 24, 2021 from the out-of-network provider.

You asked the Plan to pay an additional amount for the dental services. You say that you were in extreme pain for several weeks before you received these services. The Plan denied your request. The Plan says the correct cost share has applied to these services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation - problem focused (D0140) is not among those covered under this benefit and you are responsible for the full cost of this service ($100). You can receive services from an out-of-network provider, but you are responsible for paying the difference between what is charged by the out-of-network provider and the Plan's allowed amount for that service. The Plan covers up to two extraction procedures per calendar year. You received four extractions on March 24, 2021. The Plan agreed to cover two of the extractions with 55% coinsurance. The Plan's allowed amount for the extractions was $84. You are responsible for 55% coinsurance for these two extractions ($46.20 x2). In addition, you are responsible for any amount over the Plan's allowed amount for these extractions ($116 x2). The remaining two extractions are not covered and are fully your responsibility ($200 x2). The Plan provides coverage for the panoramic radiographic image (D0330). You are responsible for 50% coinsurance for this service. The Plan's allowed amount for the panoramic radiographic image was $62. You are responsible for 50% coinsurance ($31). In addition, you are responsible for any amount over the Plan's allowed amount for this service ($63). Your total cost share for all services received on March 24, 2021 is $918.40. Therefore, we decided that the Plan does not have to pay an additional amount for the limited oral evaluation - problem focused (D0140), the panoramic radiographic image (D0330), and the extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) received March 24, 2021 from the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cardiac computed tomography (CT) scan.

You asked the Plan to pre-approve the requested CT scan. You say that the CT scan is the only thing that can show what is wrong. The Plan denied your request. The Plan says you are asymptomatic.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested CT scan. Our physician reviewer found that you were diagnosed with atherosclerosis. Your vitals were unremarkable. The medication list did not include heart or cholesterol medications. Based on your low-risk history and no formal indication that you would change treatment based on the findings of the CT scan, there is insufficient support made for this request. The cardiac CT scan will be considered not medically necessary 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 requested CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a cardiac computed tomography (CT) scan.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on February 24, 2021 by an out of network (OON) provider.

You asked the Plan to pay for lab services. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained by the member's primary care physician.

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 lab services provided on February 24, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the joint device and related supplies (C1776) provided June 17, 2020, to June 18, 2020.
You asked the Plan to waive the coinsurance for the joint device and related supplies. You say that you do not believe the joint device should be billed as durable medical equipment. The Plan denied your request. The Plan says the coinsurance has processed correctly in this case.
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 20% coinsurance for prosthetic devices and related supplies. You have been asked to pay a total cost share of $868.26 for the joint device and related supplies ($4341.28 Medicare-allowed amount x 20% coinsurance). This item falls within the prosthetic devices and related supplies 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 coinsurance for the joint device and related supplies (C1776) provided June 17, 2020, to June 18, 2020.