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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 26, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 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 services provided by an out-of-network provider on June 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically
necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for
coverage of inpatient skilled nursing facility 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
inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that the enrollee
does not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter,
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
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve inpatient skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 29, 2020 by an out of network (OON) 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 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 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 physician services provided on October 29, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
You asked the Plan to pre-approve an additional ten (10) PT visits. The Plan denied your request. The Plan says ten (10) additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 an additional ten (10) PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.
Our physician reviewer found that in this case, the enrollee has previously been treated with outpatient physical therapy and should be independent with a home exercise program. The additional therapy services are not an appropriate duration and frequency for the enrollee's condition and therefore are 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 an additional ten (10) PT visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) PT visits.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 15, 2019 to January 3, 2020.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider billed the claims on the incorrect claim form and has not met criteria necessary for home health aide service.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim was not submitted on the appropriate 837I claim form. Additionally, the record indicates that the services rendered were custodial in nature. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 15, 2019 to January 3, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that these services were provided in good faith that reimbursement would be issued. The Plan denied your request. The Plan says 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 psychotherapy services provided on December 24, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy, 60 minutes (90837) provided on November 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you rendered treatment in good faith that the service3 will get reimbursed. The service was provided with no adequate time frame to obtain authorization for the service. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 individual psychotherapy, 60 minutes (90837) provided on November 9, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the destruction by neurolytic agent provided on January 7, 2021.

You asked the Plan to waive the copayment for the destruction by neurolytic agent. You say that you were told that the procedure would be fully covered by the Plan. 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 $275 copayment for outpatient surgery, including services provided at ambulatory surgical centers.

You have been asked to pay a $275 copayment for the destruction by neurolytic agent. The destruction by neurolytic agent 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 the destruction by neurolytic agent provided on January 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve additional routine transportation trips. You say that you have no other
transportation to dialysis treatments. The Plan denied your request. The Plan says that the requested amount
exceeds the limit listed by the plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of sixty (60) trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), the collection and application of autologous blood concentrate product (D7921), and the bone replacement graft (D7953) provided on December 9, 2020.
You asked the Plan to pay for the dental services. You say that this service should be covered. You also say that it happened when the enrollee was eating breakfast. The Plan denied your request. The Plan says extraction is not listed as a covered service. The Plan says that collection and application of autologous blood concentrate product is not listed as a covered service. The Plan says that bone replacement graft is not listed as a covered service either. The Plan also says that there is no record that you contacted them prior to the date of service to verify benefits and provider eligibility.
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 pay for the extraction (D7210), the collection and application of autologous blood concentrate product (D7921), and the bone replacement graft (D7953) provided on December 9, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Gel-One 30mg/3 ml syringe medication (J7326).

You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet step therapy criteria for coverage of this medication.

Medicare covers Part B medications when they are reasonable and necessary but 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 this medication. Our reviewer says that the enrollee does not meet step therapy criteria for coverage of this medication. Our physician reviewer found that in this case, the enrollee has bilateral osteoarthritis of the knee. The provided medical records indicate that the requested service is a new start. The medical records do not indicate that the enrollee has tried and failed the plan's preferred step one preferred agents. Additionally, the medical records do not indicate that the preferred agents would not be appropriate for the enrollee. The elements of the coverage rule are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the Gel-One 30mg/3 ml syringe medication (J7326).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided from November 17, 2020, to January 17, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the increase in 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 co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies.

You received DME and related supplies from November 17, 2020, to January 17, 2021. Therefore, you are
responsible to pay your share of the cost-sharing charges.

The total amount you owe is: $56.28.

You have been asked to pay the total coinsurance amount of $56.28 for DME and related supplies. DME and related supplies fall within the DME 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 DME and related supplies provided from November 17, 2020, to January 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a
participating provider on January 26, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you were admitted as an
inpatient and you should not have to pay for this. The Plan denied your request. The Plan says the correct
copayment has been applied.
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 $90
copayment for emergency care/in-network.
You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been
applied to the services that were provided. An emergency room visit falls within the emergency care/innetwork
benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on January 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on October 1, 2020.

You asked the Plan to waive the copayment for an ultrasound. You say that you were told that your copayment would be $25. The Plan denied your request. The Plan says the correct copayments have been applied.

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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services/in-network. 

You have been asked to pay a $110 copayment for each ultrasound. The total amount you are being asked to pay is $148.69 ($110 + $38.69 = $148.69). An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic services/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on October 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified implant procedure, by report (D6199), surgical placement of implant body: endosteal implant (D6010), second stage implant surgery (D6011), and drugs or medicaments dispensed in the office for home use (D9630) provided February 10, 2020, June 3, 2020, and June 17, 2020.
You asked the Plan to pay for the unspecified implant procedure, implant surgeries and drugs dispensed for home use. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your dental 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 pay for the unspecified implant procedure, by report (D6199), surgical placement of implant body: endosteal implant (D6010), second stage implant surgery (D6011), and drugs or medicaments dispensed in the office for home use (D9630) provided February 10, 2020, June 3, 2020, and June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the vacuum-assisted socket system.


You asked the Plan to pre-approve the vacuum-assisted socket system
. You say that you would like reconsideration because the requested system is medically necessary. The Plan denied your request. The Plan says the notes do not show why the approved socket, which includes suction system, is insufficient to meet member's needs.

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 vacuum-assisted socket system
. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found records from the prescriber do not clearly state why the approved complete replacement socket including the below knee suction socket will not meet the enrollee's needs.

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 vacuum-assisted socket system
 have not been met. Therefore, we decided that the Plan does not have to pre-approve the vacuum-assisted socket system.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the injection services provided on January 5, 2021.
You asked the Plan to waive the cost share for the services provided. You say that you should not have to pay more than your $100 copay. The Plan denied your request. The Plan says you have been asked to pay the correct amount based on your contract.
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 Medicare Part B prescription drugs. The file shows that you received a Regadenoson injection. You have been asked to pay a 20% coinsurance for the injection. The services fall within the Medicare Part B prescription drugs 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 cost share for the injection services provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 19, 2020 by an out of network provider.
You asked the Plan to pay for the office visit. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were not urgent, emergent or approved in advance.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 office visit provided on November 19, 2020 by an out of network provider.