Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast biopsy provided on January 26, 2021.

You asked the Plan to waive the copayment for a breast biopsy. You say that this was a procedure done at an office visit and not an outpatient hospital facility. 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 $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.

The record shows that you received a breast biopsy at an outpatient hospital facility on January 26, 2021. A breast biopsy is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment.

You have been asked to pay a $150 copayment for a breast biopsy. A breast biopsy falls within the outpatient surgery, including 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 a breast biopsy provided on January 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for ambulance services provided on January 
10, 2021. 
 
You asked the Plan to waive the coinsurance for ambulance services. You say that you disagree with the 
charges because the hospital had to transfer you to where they do surgeries. 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 5% 
coinsurance for ambulance services.  
 
You received ambulance services on January 10, 2021. The total allowed amount is $875.74, and 5% of that is 
$43.78. You have been asked to pay the total coinsurance amount of $43.78 for ambulance services. Ambulance 
services fall within the ambulance 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 coinsurance 
for ambulance services provided on January 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is 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 considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee was admitted with respiratory failure due to Coronavirus pneumonia.
The enrollee continues to improve. The enrollee continues to receive acute care services, and these have not
been denied. The medical record does not indicate that the enrollee requires services that they are not currently
receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied. The requested service cannot be recommended.
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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical and occupational therapy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve physical and occupational therapy to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network provider's available to the enrollee that can provide the services being requested that can also provide the services to the enrollee within the facility.
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 physical and occupational therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony, with unusual surgical complications (D7241), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and collection and application of autologous blood concentrate product (D7921).
You asked the Plan to pre-approve removal of impacted tooth with complications, cone beam CT scan and collection and application of autologous blood concentrate product. You say that its necessary for an oral surgeon to remove the tooth. The Plan denied your request. The Plan says these services are not covered under your benefits.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony, with unusual surgical complications (D7241), cone beam computed tomography (CT) capture and interpretation with limited field of view - less than one whole jaw (D0364), and collection and application of autologous blood concentrate product (D7921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210), alveoloplasty in conjunction with extraction (D7311), a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220).

You asked the Plan to pre-approve an extraction, alveoloplasty in conjunction with extraction, a limited oral evaluation, and an intraoral periapical radiographic image. You say that the services are necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.

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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an extraction (D7210), alveoloplasty in conjunction with extraction (D7311), a limited oral evaluation (D0140), and an intraoral periapical radiographic image (D0220).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (E0466).

You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because the documentation submitted supports usage and compliance. The Plan denied your request. The Plan says the denial is consistent with Medicare regulations.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our reviewer says that a home ventilator is not medically necessary for you. Our physician reviewer found the COPD diagnosis has not been confirmed with pulmonary function testing. There is no documentation of Carbon Dioxide retention. There is no diagnosis of neuromuscular disease or thoracic disease. There is no evidence that BiPAP has been tried and failed and Medicare does not cover a home ventilator when used as BiPAP.

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve radiofrequency ablation. You say that the requested radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the requested radiofrequency ablation is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We 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 radiofrequency ablation. Our reviewer says that the requested radiofrequency ablation is not medically necessary. Our physician reviewer found the enrollee has chronic bilateral sacroilitis. She had prior radiofrequency ablation of the lateral sacral branches in 2018 and achieved 90% pain relief for 6 months. The pain has returned in the same pattern as before and she would like the radiofrequency ablation repeated. This procedure is considered experimental/investigational due to the wide variation in efficacy reported in the literature. The request is considered 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for spirometry provided on March 18, 2021.

You asked the Plan to waive the copayment for spirometry. You say that you already paid the $45 copayment and should not be responsible for the charges. 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 $20 copayment for non-radiological diagnostic services.

You have been asked to pay a $20 copayment for spirometry. Spirometry falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for spirometry provided on March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Prolaris Prostate Cancer Genomic Assay.
You asked the Plan to pre-approve the Prolaris Prostate Cancer Genomic Assay. You say that the requested Prolaris Prostate Cancer Genomic Assay is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Prolaris Prostate Cancer Genomic Assay.
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 Prolaris Prostate Cancer Genomic Assay. Our reviewer says that the enrollee does not meet criteria for the requested Prolaris Prostate Cancer Genomic Assay. Our physician reviewer found this enrollee has a high-risk prostate cancer with a Gleason score of 7. He does not meet coverage criteria for Prolaris testing. The service 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 the Prolaris Prostate Cancer Genomic Assay have not been met. Therefore, we decided that the Plan does not have to pre-approve the Prolaris Prostate Cancer Genomic Assay.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7210 x19), removal of residual tooth roots (D7250), and regional block anesthesia (D9211).
You asked the Plan to pre-approve extractions, removal of residual tooth roots, and regional block anesthesia. You say that the services are medically necessary. The Plan denied your request. The Plan says the extractions are a covered benefit, but you have exceeded the frequency limit of three every year. The regional block anesthesia 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions, removal of residual tooth roots, and regional block anesthesia have not been met. Specifically, the record shows that you had exceeded the frequency limit for extractions. Additionally, the regional block anesthesia is not a covered service. Therefore, we decided that the Plan does not have to pre-approve extractions (D7210 x19), removal of residual tooth roots (D7250), and regional block anesthesia (D9211).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF
admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the
hospital the member had stabilized medically. The member did not require any skilled nursing or rehab
services on a daily basis at an inpatient level of care. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. The member did not have any parental medication, complex wound care or nutrition given via a feeding tube. He was medically stable without any acute exacerbations of chronic medical problems. His 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan tablets.
You asked the Plan to pre-approve Xifaxan tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Xifaxan tablets are not covered under the enrollee's Medicare Part B benefit.
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 Xifaxan tablets.
Benefits for Xifaxan tablets 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires mid-to-long term acute care. The Plan denied your request. The Plan says the LTACH services you are requesting do not meet the requirements for approval.
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. Our physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer found that the are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve the LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent (J3590).
You asked the Plan to pre-approve Praluent. You say that you would like this drug to be reconsidered for coverage. The Plan denied your request. The Plan says Praluent is a self-administered drug and is not covered under the enrollee's plan under any normal circumstances.
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 Praluent (J3590).
Benefits for Praluent 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve office visit services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says that there are in-network Neurosurgeon's available to the enrollee that can provide the services being requested.
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 office visit services to be provided by an out-of-network (OON) provider.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 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 admission to a LTACH is not medically necessary. Our physician reviewer found the 
enrollee was admitted with congestive heart failure exacerbation of restrictive cardiomyopathy. The enrollee is 
hemodynamically unstable, requiring inotropic support. The enrollee continues to receive acute care services, 
and these have not been denied.  The medical record does not indicate that the enrollee requires services that he 
is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied.  The requested service cannot be recommended. 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.