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

We decided that the Plan does not have to reimburse you forthe ambulance services provided on October 13, 2019.You asked the Plan to reimburse you forthe ambulance services. You say that the ambulance services were medically necessary.The Plan denied your request. The Plan says ambulance services outside of the United States is not covered.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.The Plan does not cover ambulance services outside the United States. Therefore, we decided that the Plan does not haveto reimburse you forthe ambulance services provided on October 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the 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 admission is not medically necessary.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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has a history of stroke. She was seen by her primary care physician after a fall and was noted to have irregular gait and left-sided weakness. There are no further details of her functional status or documentation of physical or occupational therapy evaluations. She has no skilled nursing needs. She has skilled therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services havenot been met.Therefore, we decided that the Plan does not have to pre-approvea skilled nursing facility (SNF) admission for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visits. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you have in network, contracted providers within your service area that can provide 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided to the enrollee from May 23, 2018 to December31, 2018.You asked the Plan to pay forSNF services. You say that SNF services were medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for SNF services were not met.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 thePlan was correct in denying the request to pay for SNF services. Our reviewer says that daily skilled services were not necessary. Our physician reviewer found based on the medical records provided, there were no identifiable daily skilled nursing or daily skilled therapy services required by the enrollee at a SNF level of care for the dates of service in question.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 services were not met.Therefore, we decided that the Plan does not have to pay forskilled nursing facility (SNF) services provided to the enrollee from May 23, 2018 to December 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiothoracic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says your condition can be evaluated by a cardiothoracic surgeon within the network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve cardiothoracic services to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of chest wall respiratory sensor electrode (0466T).You asked the Plan to pre-approve the insertion of chest wall respiratory sensor electrode. You say that this procedure is medically necessary for the treatment of your condition. The Plandenied your request. The Plan says this service is not a covered benefit in the state of Tennessee.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of chest wall respiratory sensor electrode have not been met. Specifically, per Local Coverage Article: Billing and Coding: Non-Covered Category III CPT Codes (A56480), the insertion of a chest wall respiratory sensor electrode is a non-covered benefit. Therefore, we decided that the Plan does not have to pre-approve the insertion of chest wall respiratory sensor electrode (0466T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forhemorrhoid removal provided on November 8, 2019.You asked the Plan to waive the copayment forthe hemorrhoid removal. You say that the surgery was performed in the office. You say that you expected to be charged $35 for the visit.The Plan denied your request. The Plan says the copayment applied correctly.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 $250 copayment for in-network outpatient surgery services.You have been asked to pay a $250 copayment the hemorrhoid removal. The hemorrhoid removalfalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The hemorrhoid removalis considered a surgical procedure that was billed by the hospital. 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 forhemorrhoid removal provided on November 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of 2 teeth to an existing denture (D5650) provided on August 27, 2019.
You asked the Plan to pay for the dental services. You say that you had 2 teeth extracted. You say that you needed to add 2 teeth to your existing partial because of it. You also say that you are on a limited income. The Plan denied your request. The Plan says the addition of a tooth to an existing partial denture is not a covered service.
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 addition of a tooth to an existing partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the addition of 2 teeth to an existing denture (D5650) provided on August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve Prolia. You say that Prolia is the best choice for the enrollee.The Plan denied your request. The Plan says that this is not medically necessary as you have not shown a contraindication as to why the enrollee cannot use zoledronic acid.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The enrollee has not tried Zoledronic acid. The documentation is insufficient to demonstrate that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. There is insufficient data from clinical trials to demonstrate that Prolia would be more effective than zoledronic acid in a patient who has previously been treated with an oral bisphosphonate. Previous polio is not a contraindication to Zoledronic acid, nor is a GFR > 60. Our physician reviewer found the enrollee's condition does not meet step therapy criteria for Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe continued skilled nursing facility (SNF) services.You asked the Plan to pre-approvethe continued SNF services. You say that you are asking for the plan to cover the cost for a few more months until he can get strong enough to walk and go homeThe Plan denied your request. The Plan says the 100 day SNF benefit has been exceeded.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from September 20, 2019 to January 18, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row.Therefore, we decided that the Plan does not have to pre-approvethe continued skilled nursing facility (SNF) services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe criticalcare services provided on June 28, 2019.You asked the Plan to pay forthe physician services. You say that the enrollee was discharged prior to the hospice election on the same date of service. You say that your claim should be paid by the enrollee's Medicare replacement plan, not traditional Medicare since there is no overlap.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe critical care services provided on June 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation first intraoral periapical x-ray provided on November 19, 2019.You asked the Plan to pay forthe limited oral evaluation intraoral periapical x-ray. You say that you waitedlonger to be seen than for the provider to say she was not able to do anything. You also say that this provider wanted you to come back another time.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 Plan only covers cleanings, routine oral exams, comprehensive oral exams, and bitewing x-rays.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation first intraoral periapical x-ray provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the IRF admission 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 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 that the complexity of the patient's nursing, medical, and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient
does require skilled physical and occupational therapy; however, she does not require treatment in an intensive
rehabilitation therapy program. The medical records provided indicate that there is concern that the patient
would not be able to fully participate in and benefit from an intensive rehabilitation therapy program provided
in an inpatient rehabilitation facility.
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 an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvea surgical facility and general anesthesia for the enrollee's dental services.You asked the Plan to pre-approvea surgical facility and general anesthesia. You say that it is medically necessary for the enrollee to have the dental services in an operating room under general anesthesia.The Plan denied your request. The Plan says that it is not medically necessary for the enrollee to have the dental services in an operating room under general anesthesia.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a surgical facility and general anesthesia. Our reviewer says that it is medically necessary for the enrollee to have the dental services in an operating room under general anesthesia. Our physician reviewer found a review of the enrollee's dental and medical records indicate that the enrollee has several chronically and acutely infected teeth causing pain and swelling of the face and surrounding structures. The pertinent medical history includes obesity, asthma, hypertension, anxiety, obstructive sleep apnea and other medical issues. Due to the number of teeth to be extracted (12), the length of the procedure and the enrollee's significant medical history, it would be in the enrollee's best interest to have the procedure performed in the operating room under general anesthesia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a surgical facility and general anesthesia have been met.Therefore, we decided that the Plan has to pre-approvea surgical facility and general anesthesia for the enrollee's dental services.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on August 7, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that you did not request this service. You say the request came from your insurance. You say you are retired and on a limited income.The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says thatyou must pay a $150 copayment per trip, each way. You have been asked to pay a $150 copayment for the ambulance ride. The ambulance ride falls within "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 copayment forthe ambulance ride provided on August 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on February 15,
2019.
You asked the Plan to waive the copayment for the ED visit. You say that you waited for hours in the waiting
room. You say that you did not receive any services. The Plan denied your request. The Plan says the
copayment applied correctly.
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 $120
copayment for emergency services in an emergency room.
You have been asked to pay a $120 copayment for the ED visit. The ED visit falls within the "Emergency care"
benefit category. The records show that you were treated in the emergency department. 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 ED visit provided on February 15, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a kidney transplant evaluation.You asked the Plan to pre-approve the kidney transplant evaluation services. You say that the enrollee is eligible to receive a kidney transplant, as her eGFr is 10. You say that the Plan is delaying the enrollee a life-saving procedure. You say that this is contrary to the current medical standard of care and potentially decreases the enrollee's prospective lifespan.The Plan denied your request. The Plan says that the records provided do not show a sign of kidney failure or of fluid/electrolyte imbalance. The Plan says that the enrollee is not on dialysis and does not meet the criteria for coverage of a kidney transplant.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 kidney transplant evaluation services. Our reviewer says that the requested kidney transplant evaluation services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's eGFr of under 20 is accepted criteria for coverage. Our physician reviewer found that being on dialysis is not necessary for evaluation for kidney transplant. This is standard of care and a typical referral for kidney transplantation.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 kidney transplant evaluation services have been met.Therefore, we decided that the Plan has to pre-approve a kidney transplant evaluation.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.