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

We decided that the Plan does not have to pre-approve omeprazole.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 omeprazole.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) rendered on September 15, 2020.
You asked the Plan to waive the copayment for these services. You say that the copayment is a financial hardship. The Plan denied your request. The Plan says the copayment was 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 $160 copayment for each Medicare-covered radiological diagnostic service, not including x-rays.
Review of the fie shows that you received an MRI of the brain stem on September 15, 2020. You have been asked to pay a $160 copayment for these services. These services fall within the Medicare-covered radiological diagnostic service, not including x-rays 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 magnetic resonance imaging (MRI) rendered on September 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on February 6, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above,are not covered.The testing at issue in this appeal (A1c testing, urine creatinine assay, urinalysis) was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on February 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe annual physical exam rendered on October 15, 2020.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says the services exceeded the benefit limit.The Plan must follow Medicare rules. The rules say that Medicare will cover one physical exam per lifetime. The Plan covers one physical exam per calendar year.We looked at the file and the Plan's rules. The file shows that you previously had an annual physical exam on September 10, 2020,for which the Plan approved and paid. The physical exam on October 15, 2020,is not covered because the Plan covers only one physical exam per calendar year.Therefore, we decided that the Plan does not have to pay forthe annual physical exam rendered on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided  September 21, 2020.You askedthe Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 21, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on September 21, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 12, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until August 26, 2020. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided on March 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate for 4 extractions (D7210), the consultation (D9310), and the incisional biopsy of soft tissue (D7286) provided on September 15, 2020.
You asked the Plan to pay the in network rate for 1 additional extraction, the consultation, and the biopsy. You say that you paid up front for the extractions. You say that it is wrong to charge for a full biopsy when it was collected as a result of another procedure. You also say that the provider office was listed as in network. The Plan denied your request. The Plan says 3 extractions per calendar year are covered. The Plan says that the frequency limit has been exceeded. The Plan says the consultation is not listed as a covered service. The Plan also says that the incisional biopsy of soft tissue 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, the frequency limit of 3 extractions per calendar year has been exceeded. The record shows that the Plan paid for 3 extractions that you received on this date of service. Additionally, the consultation and biopsy are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in network rate for 4 extractions (D7210), the consultation (D9310), and the incisional biopsy of soft tissue (D7286) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services and x-rays provided on September 30, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forphysician services and x-rays. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-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 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 forphysician services and x-rays provided on September 30, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory servicesprovided on August 25, 2020.You asked the Plan to pay for the laboratory services. You say that you were unaware that the provider was an out-of-network provider.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 and the ordering/referring provider are notnetwork providerswith the Plan. The Plan did not pre-approve the laboratory services.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 laboratory servicesprovided on August 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePegfilgrastim.You asked the Plan to pre-approvePegfilgrastim. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medicallyaccepted as safe and effective or appropriate for the particular use. 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 Pegfilgrastim. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has myelodysplasia (MDS). Nuelasta or its biosimilar(fulphilia) is approved to prevent febrile neutroepnia for enrollees receiving myelosuppressive chemotherapy for non myeloid malignancies. MDS is a myeloid malignancy. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Pegfilgrastim have not been met.Therefore, we decided that the Plan does not have to pre-approvePegfilgrastim.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran emergency room visit provided on August 13, 2020.You asked the Plan to waive the copayment foremergency room visit. You say that you were told you would have to wait 6 hours, so you left and never saw a doctor.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $90 copayment for emergency room visit. You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency Care 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 foran emergency room visit provided on August 13, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the cleaning (D1110), bitewing x-rays 
(D0274), the unspecified preventive service (D1999), the crown (D2740), core build up (D2950), and the oral 
exam (D0120) provided from May 20, 2020, to June 24, 2020. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you received a bill for 
$1,078.25. You say that you contacted the plan and they advised the provider was out of network. You say that 
you contacted the dental office and they said they would take care of it. You say that the dental office advised 
you owed $329, which you paid. You say that you received another statement saying you owe $890.75. You 
say that the dental office advised you are paid in full with them and the balance is due to the plan. The Plan 
denied your request. The Plan says the provider in this case is out of network. The Plan says there is a 50% 
coinsurance for preventive dental services that you receive out of network. The Plan says there is a 75% 
coinsurance for crowns that you receive out of network. The Plan also says that core build up and the 
unspecified preventive service are not listed as covered services. 
 
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, dental services that you receive out of 
network may have a higher cost share amount. The record shows that the Plan paid 50% of the allowed amount 
for the cleaning, bitewing x-rays, and oral exam. The record shows that the Plan paid 25% of the allowed 
amount for the crown. Additionally, core build up and the unspecified preventive service are not listed as 
covered services. Therefore, we decided that the Plan does not have to pay the in network rate for the cleaning 
(D1110), bitewing x-rays (D0274), the unspecified preventive service (D1999), the crown (D2740), core build 
up (D2950), and the oral exam (D0120) provided from May 20, 2020, to June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office consultation (99244) and office visit (99204) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve Office visit and consultation. You say that the services are medically necessary. The Plan denied your request. The Plan says medically necessary care is available in 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 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 office consultation (99244) and office visit (99204) to be provided 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 an outpatient surgery provided by a participating provider on August 18, 2020.You asked the Plan to waive the copayment foran outpatient surgery. You say that you did not have this done in a hospital. 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 $350 copayment for outpatient surgery/in-network. You have been asked to pay a $350 copayment for an outpatient surgery. The correct copayment has been applied to the services that were provided. An outpatient surgery falls within the outpatient surgery/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 outpatient surgery provided by a participating provider on August 18, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen supplies provided from September 8, 2019, through November 8, 2019.
You asked the Plan to pay for the oxygen supplies. The Plan denied your request. The Plan says you are responsible for the claim denial when the services are provided by an out-of-network provider.
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 did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for oxygen supplies provided from September 8, 2019, through November 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee does not need three hours a day of therapy, her medical illnesses are stable and she does not need a physician to monitor them three times a week.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. 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 was admitted for respiratory failure, pneumonia and congestive heart failure. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore, we decided that thePlan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you could not wait until the following year to have this problem addressed.The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit 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 Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on June 16, 2020, and your problem focused limited oral evaluation (D0140) benefit had been exhausted.Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Isosorbide dinitrate 40 mg tablet.
You asked the Plan to pre-approve Isosorb din. You say that this service is medically necessary. The Plan
denied your request. The Plan says this medication does not fall 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 the Isosorbide dinitrate 40
mg tablet.
Benefits for Isosorb din may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe therapeutic procedures (97110) provided on September 11, 2019.You asked the Plan to pay forthe therapeutic procedures. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says coverage of chiropractic service is specifically limited to treatment by means of manual manipulation.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe therapeutic procedures (97110) provided on September 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on August 18, 2020 by an OON provider.You asked the Plan to pay forthe subsequent nursing facility care. You say that the rendering physician depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. You also say that your physician provided medically necessary services to the enrollee in good faith.The Plan denied your request. The Plan says there is no evidence that the provider contacted the Plan to verify insurance,current eligibility, or authorization requirements. The Plan also says that prior authorization was not obtained.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 did not pre-approve the item/service atissue. 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 forthe subsequent nursing facility care provided on August 18, 2020 by an OON provider.