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

We decided that the Plan does not have to pay forthe acute inpatient hospital care provided from October 29, 2019 to November 1, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says observation care, not inpatient, was authorized.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted October 29, 2019 for an elective right knee arthroplasty.He tolerated the procedure without complication. He was evaluated by physical therapy. He was stable post-procedure and was discharged home on November 1, 2019. The review has determined that the record did not show that at the time of inpatient admissionthe admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofacute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from October 29, 2019 to November 1, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approveadditional routine transportation trips.You asked the Plan to pre-approvethe additional routine transportation trips. You say that you have remaining appointments and require further routine transportation coverage.The Plan denied your request. The Plan says that the enrollee has used 50 trips and has exhausted her benefit for the calendar year.Medicare does not cover transportin 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 up to 50 one-way routine transportation trips per calendar year. Medicare rules also state that the Plan must provide enrollees with a clear and accurate description of any supplemental benefits and any conditions associated with the use of receipt of the benefits. We looked at your request, the records in the case file, and the rules.The records show that the enrollee received 39 one-way routine transportation trips in the 2020 calendar year. While the trip log did notate that there were "no show" trips, the Plan contract does not clearly advise that missedtrips count toward the enrollee's total trip tally for the year. It is the Plan's responsibility to write contract language in a manner that clearly describes the benefits and any conditions associated with receipt of the benefits. In this case, the Plan's contract language did not clearly describe that condition. Trips that the enrollee did not take cannot be counted toward her total trip allowance.Based on this information, we decided that the Plan's rules for coverage of the additional routine transportation trips have been met.Therefore, we decided that the Plan has to pre-approveadditional routine transportation trips. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemounting hardware for an alternate drive system, calf pads, seat belt, and an Omni 2 Control 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 services cannot be separately approved.The Plan must follow Medicare rules. Medicare rules say that the alternative drive system, calf support, seat belt, and Omni 2 control are included in the approved PWC package.We looked at the file and Medicare rules. The Plan has approved a Group 3 PWC with power tilt and recline and power elevating leg rests for the enrollee. The approved PWC includes the mounting hardware, calf pads, seat belt, and Omni 2 Control. These items are not separately approved, as they are included in the items that have already been approved by the Plan.Therefore, we decided that the Plan does not have to pre-approvemounting hardware for an alternate drive system, calf pads, seat belt, and an Omni 2 Control for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe monitored anesthesia care (MAC) rendered to you on March 12, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were not medically necessary.The Plan must follow Medicare rules. Medicarerules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted records show that you underwent a screening colonoscopy in March of 2019 with MAC. Your blood pressure, oxygen saturation, and pulse rate were all within normal limits. A colonoscopy is typically performed with conscious sedation. The records do not support that MAC was required for the procedure. The MAC was 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 these services have not been met.Therefore, we decided that the Plan does not have to pay forthe monitored anesthesia care (MAC) rendered to you on March 12, 2019. The Plan references Local Coverage Determination (LCD) L32628 in their determination; however, this LCD was not binding for the date of service at issue and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepodiatry services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvepodiatry services. You say that you are trying to see if more can be done to help your foot.The Plan denied your request. The Plan says there are in-network providersavailable 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-approvepodiatry services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D7953, D6010, D4266) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe denied codes are not covered by the dental plan.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 Planoffers 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 Plandoes not haveto pre-approvedental services (D7953, D6010, D4266) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvesinus surgery (ethmoid, frontal, and sphenoid).You asked the Planto pre-approvethe surgery. You say that this ismedically necessary.The Plandenied your request. The Plansaysthere is no evidence of active disease in the sinuses.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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the physical examination and CT scan findings do not support the evidence of chronic sinusitis. The physical exam findings for the nose are not typical findings for chronic sinusitis. The CT scan of the sinus did not show evidenceof sinus disease that warrants therequested procedure.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvesinus surgery (ethmoid, frontal, and sphenoid).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have topay forout of network outpatient surgery provided to the enrollee on September 24, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 forout of network outpatient surgery provided to the enrollee on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveendovenous ablation therapy and duplex scan to be provided by an out of network (OON) provider.You asked the Plan to pre-approveendovenous ablation therapy and duplex scan. You say that you would like authorization to supply these services.The Plan denied your request. The Plan says there are in-network providers available.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. Please contact the Plan for in-network providers available for these services. 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-approveendovenous ablation therapy and duplex scan 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 forthe medical services provided to the enrollee by an out-of-network provider on September 26, 2019, and October 2, 2019.You asked the Plan to pay fortheservices. 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 has network providers available who can provide the servicesat 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 forthe medical services provided to theenrollee by an out-of-network provider on September 26, 2019, and October 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe bed rails.You asked the Plan to pre-approvebed rails. You say that you are requesting an appeal because you need longer bed rails.The Plan denied your request. The Plan says Bed rails is not covered as a separate benefit. Bed rails are only covered as an accessory to a covered hospital bed and you do not have a hospital bed.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bed rails have not been met.Therefore, we decided that the Plan does not have to pre-approvethe bed rails.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea replacement pair of eyeglass frames and lenses.You asked the Planto pre-approvethe vision care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe supplemental vision benefit does not provide coverage for replacing lost eyewear.The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pre-approve are considered routine vision services or eyewear. There is $45.03 remaining of your allowance -the full amount of the requestedsupplies cannot be paid for.Therefore, we decided that the Plandoes not haveto pre-approvea replacement pair of eyeglass frames and lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 23, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participatingfacilities require prior authorization as outlined in the enrollee's EOC.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 services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by anout-of-network provider on October 23, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay forBLS emergency ambulance service (A0429) and ground mileage (A0425) and August 19, 2019.You asked the Plan to pay forthe ambulance service. You say that you had a bad fall in a public parking lot and someone called an ambulance. The paramedics tried to stop the bleeding but it would not stop so you are confused why the plan has denied payment.The Plan denied your request. The Plan says that this happened in a public parking lot at a Gooodwill store. The store would be reliable to pay for any injuries that are sustained on their properties unless there is formal documentation that states otherwise.The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergentin nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. Afall with head trauma and uncontrolled bleeding is clearly something that a prudent layperson would believe required immediate care. The plan has failed to show that payment can reasonably be expected to be made under a liability policy. There is no evidence that any such liability claim is being filed or that it will be paid promptly. If payment is eventually made by such a policy, then the plan would be allowed to recoup the cost of this ambulance transportation from that payment.We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay forBLS emergencyambulance service (A0429) and ground mileage (A0425) and August 19, 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 toreview. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 9, 2019.You asked the Planto pay forthe 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 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 forthe medical services provided to the enrollee by an out-of-network provider on July 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea custom abutment (D6057) and an abutment supported crown (D6058).You asked the Plan to pre-approvethe dental services. You say that the crown, at least, should be covered. The Plan denied your request. The Plan says custom abutment is not listed as a covered service. The Plan also says that abutment supported crown is not listed as 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, custom abutments and abutment supported crowns are not among those covered under thisbenefit.Therefore, we decided that the Plan does not have to pre-approvea custom abutment (D6057) and an abutment supported crown (D6058).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for eye examinations to be provided by "the doctor". You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgentcareor if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.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 services. Therefore, we decided that the Plan does not have to pre-approve physician's services for eye examinations to be provided by "the doctor".
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvean extraction of one tooth (D7210) to be performed by an Oral Surgeon.You asked the Plan to pre-approvean extraction of one tooth to be performed by an Oral Surgeon. You say that the services are necessary.The Plan denied yourrequest. The Plan says the services must be performed by a participating general dentist. Therefore, coverage criteria has not met.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. The Plan covers a simple extraction or surgical removal of an erupted tooth once per year when provided by a participating general dentist.We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an extraction of one tooth to be performed by an Oral Surgeon have not been met.Therefore, we decided that the Plan does not have to pre-approvean extraction of one tooth (D7210) to be performed by an Oral Surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsuranceforthe bladder measurement provided on October 21, 2019.You asked the Plan to waive the coinsurance forthe bladder measurement. You say that this should be considered in-network.The Plan denied your request. The Plan says the coinsurance 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 $45 copayment for provider and professional services at an in-network specialist's office and 50% coinsurance for provider and professional services at an out-of-network specialist's office.You have been asked to pay $6.44, which is 50% of the allowed amount for the bladder measurement. The allowed amount is $12.88 (50% x $12.88 = $6.44). The bladder measurement falls within the "Physician/Practitioner services, including doctor's office visits" 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 forthe bladder measurement provided on October 21, 2019.