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

We decided that the Plan does not have to pay for the filling, 2 surfaces, (D2392) for tooth # 31 provided on November 14, 2019.You asked the Plan to pay for the filling for tooth # 31. You say that you are on a fixed income. You also say that this bill does not fit into your budget.The Plan denied your request. The Plan says 2 fillings per calendar year are covered. The Plan also says the frequency limit has been exceeded.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 and fillings are a covered service, the frequency limit has been exceeded. The record shows that the Plan approved and paid for 2 fillings that you received on November 14, 2019.Therefore, we decided that the Plan does not have to pay for the filling, 2 surfaces, (D2392) for tooth # 31 provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941, 98943) rendered by an out of network provider (OON) on October 26, 2019. You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial as your chiropractor is in your provider network. The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941, 98943) rendered by the out of network (OON) provider on October 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 11, 2019 to September 9, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 11, 2019 to September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate specific antigen (PSA) screening rendered to you on November 25, 2019.
You asked the Plan to pay for these services. You say that you were given the order by the provider. The Plan denied your request. The Plan says the testing exceeds the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that PSA screening is covered once every 12 months. We looked at the file and Medicare rules. The file shows that you previously received a PSA screening on January 4, 2019 for which the Plan approved and paid. The testing on November 25, 2019 was performed less than 12 months from your previously covered testing. Therefore, we decided that the Plan does not have to pay for the prostate specific antigen (PSA) screening rendered to you on November 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 26, 2019 to September 24, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient SNF level of care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 services have not been met.Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from August 26, 2019 to September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.
You asked the Plan to pre-approve the requested service. The Plan denied your request. The Plan says the submitted documentation does not justify the requested service.
The Plan follows Medicare rules. Medicare rules say that sacroiliac joint injections are only covered under certain medical indications.
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 service. Our physician reviewer found that you have chronic low back pain and sacroiliitis. You had a prior SI joint injection which provided you with 50-60% pain relief for one month. The prior SI joint injection did not provide the required level of pain relief according to the criteria. Therefore, the requested service 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 the requested service have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for One Touch Veriotest strips (A4253).You asked the Plan to pay for the non-preferred bran of test strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there are no medical records or a certificate of medical necessity provided to show the reason for using this non-preferred strip.The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-preferred bran of test strips. have not been met. Specifically, no medical records have been submitted to determine the medical necessity for use of a non-preferred brand of test strip. Therefore, we decided that the Plan does not have to pay for One Touch Verio test strips (A4253).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dermatology services. You say that you waited too long for an office visit with the provider your primary physician referred you to. You say that you would like to have an office visit with this provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 dermatology 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 the medical services provided on May 31, 2019 to the enrollee by a non-participating provider.
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 were rendered by a non-participating provider without prior authorization.
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 has network providers available who can provide 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 medical services provided on May 31, 2019 to the enrollee by a non-participating provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold you harmless for operative services provided on June 19, 2019 through June 20, 2019.
You asked the Plan to hold you harmless for the operative services. You say that you would like reconsideration because you were kept in the hospital an extra day due to a referral delay. The Plan denied your request. The Plan says that the claim cannot be priced for payment as it has been billed incorrectly.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the operative services by the facility. The facility is a contract provider. The file does not show that Plan provided notice that the operative services would not be covered. Under Medicare rules, this means the operative services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for operative services provided on June 19, 2019 through June 20, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methotrexate for the enrollee. You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B. 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 Methotrexate for the enrollee.
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 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 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 you were medically stable with no evidence of need for supervision by a physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You are functionally doing well. You may benefit from further physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF admission is not medically necessary based on your current functional status and medical stability.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe outpatient hospital services provided to enrollee on May 21, 2019.You asked the Plan to waive the copay for the services provided. You say that you were charged $40 for the visits in the past.The Plan denied your request. The Plan says the cost share was applied correctly per the enrollee's benefit.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 $395 copay for services provided to you at an outpatient hospital. The enrollee has been asked to pay a $237.35 for the services provided. Because the amount is less than the $395 copay, the enrollee was charged the lesser amount. The services fall within the outpatient surgery and other medical services provided at hospital outpatient facilities 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 copay forthe outpatient hospital services provided to enrollee on May 21, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe medical services provided on October 30, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says that there is no network deficiency for the services, and alternate network providers were found.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthat you receive your care from a provider who is eligible to provide services under Original Medicare.We looked at the file and Medicare rules. The provider at issue is not a network provider with the plan. However, the enrollee can receive care from a provider who is eligible to provide services under Original Medicare. The documentation did not indicate the provider at issue is not eligible to provide services under Original Medicare. Based on this information, wedecided that Medicare rules for coverage of the services provided have been met.Therefore, we decided that the Plan has to pay forthe medical services provided on October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveMRI of the neck spine.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no apparent history of injury or previous treatment.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found cervical spine x-rays have been ordered but there are no results in the provided records. Neurological exam is normal with normal strength and reflexes upper extremities. There is no history of tumor or trauma. No attempt at conservative therapy including PT is in the records. Absent any red flags, medical necessity for MRI of the cervical spine is not established in the records provided.We lookedat this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met.Therefore, we decided that the Plandoes not haveto pre-approveMRI of the neck spine.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan for enrollee. You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessarybut allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has unilateral primary osteoarthritis of the left knee. She has not tried and failed the plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be less effective or contraindicated; therefore, Hyalgan is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services providedon February 28, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the care was not prior authorized, urgent, or emergent.
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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair power tilt and recline, and free form custom back kit.You asked the Plan to pre-approve a manual wheelchair power tilt and recline, and free form custom back kit.You say that the enrollee needs a custom wheelchair due to an inability to maintain postural alignment.The Plan denied your request. The Plan says power tilt and recline is only covered on a power wheelchair and custom back kit is not covered by Medicare in a facility.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that a manual wheelchair power tilt and recline, and free form custom back kit is being requested for use in a SNF. Power tilt and recline is only covered on a power wheelchair. The facility must meet the enrollee's positioning needs. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair, power tilt and recline, and free form custom back kit.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued inpatient skilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee no longer requires inpatient skilled therapies or services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs.  There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued inpatient skilled nursing facility (SNF) services for the enrollee.