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

We decided that the Plan does not have to pay for inpatient hospital care services.

You asked the Plan to pay for the inpatient hospital care services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Plan is secondary payer.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the inpatient hospital care services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for inpatient hospital care services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for
coverage of LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care. The enrollee does not require services at the
LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 13, 2020 by an out of network (OON) provider.

You asked the Plan to pay for laboratory testing. You say that Medicare rules prohibit the Plan from preventing or hindering your right to payment recovery, including reimbursement on claims denied for lack of prior authorization or referral. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with 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 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 medical services provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a urinary tract infection with hypotension. She was treated for a hip fracture after a fall during the hospitalization. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 1, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

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 office visit provided on September 1, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of radiographic images.
You say that you only asked for a cleaning and you received services you did not ask for. The Plan denied your
request. The Plan says you received these services, so the frequency limitation has been exceeded.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the services at issue exceed the
frequency and therefore are not covered under this benefit. Therefore, we decided that the Plan does not have to
pay for dental services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a
participating provider on October 8, 2020.

You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you had this done
because your doctor advanced you they had found something. 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 $30
copayment for outpatient diagnostic tests/outpatient diagnostic tests.

You have been asked to pay a $30 copayment for a diagnostic ultrasound. Since diagnostic radiology services
were provided, the correct copayment has been applied. A diagnostic ultrasound falls within the outpatient
diagnostic tests/outpatient diagnostic tests 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 a diagnostic ultrasound provided by a participating provider on October 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Evenity.

You asked the Plan to pre-approve Evenity. You say that you took Evenity in the past. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of bisphosphonates, Reclast, or Fosamax before it will cover Evenity.

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 Evenity. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Evenity. Our physician reviewer found you have not tried and failed the Plan's preferred drugs of bisphosphonates, Reclast, or Fosamax. There is no documentation indicating that these drugs would likely be less effective and/or have adverse effects for you. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external infusion pump rental with related supplies
provided from August 5, 2019, through October 22, 2019.

You asked the Plan to pay for the infusion pump rental. You say that these claims should be paid due to
medical necessity. The Plan denied your request. The Plan says these infusions were started during physician
visits. As such, the payment for the equipment is included in the payment made to the provider who began the
infusion.

The Plan must follow Medicare rules. Medicare rules say that when drug infusions that require prolonged
administration through an external pump are initiated in a physician's office, payment for the drug and the
equipment is included in the payment made to the physician or facility.

The file shows that these infusions were begun in the treating provider's office. Payment for the related
equipment cannot be made separately to the equipment supplier as it is included in the payment to the
physician. Therefore, we decided that the Plan does not have to pay for the external infusion pump rental with
related supplies provided from August 5, 2019, through October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hearing aids, digital, monaural, BTE
(V5257) purchased March 2, 2020.

You asked the Plan to waive the copayment for the hearing aids. You say that you are requesting a refund of
$750 because your hearing aids kept slipping off of your years and you needed to make an appointment but due
to the pandemic the offices were closed. The Plan denied your request. The Plan says the claim processed and
the correct copayment was applied per the Evidence of Coverage.

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 $375
copayment for each private-labeled reserve premium hearing aid.

You have been asked to pay $750 ($375 + $375 = $750) for the hearing aids. The hearing aids falls within the
Hearing 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 for the hearing aids,
digital, monaural, BTE (V5257) purchased March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra 162 mg/0.9 mL syringe.

You asked the Plan to pre-approve Actemra. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Part B programs can only provide limited benefits for prescription drugs.

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 Actemra 162 mg/0.9 mL syringe.

Benefits for Actemra 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the over-the-counter items you purchased on October 9,
2020.
You asked the Plan to pay for the items. The Plan denied your request. The Plan says the benefit limit was
reached.
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 there is a $17
allowance every month for eligible over-the-counter items.
Review of the file shows that you purchased over-the-counter items on October 9, 2020. The Plan contract
clearly states that there is a $17 benefit limit every month for over-the-counter items. However, the Plan
increased this benefit limit to $22 in June 2020. The records show that you purchased over-the-counter items
on October 12, 2020, which the Plan paid $22 toward. The reimbursement requested for the items in question
was submitted after October 12, 2020. This means that you have been asked to pay the correct amount based on
your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the over-the-counter
items you purchased on October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a bilateral knee arthroplasty (27447-RT, 27447-LT).

You asked the Plan to pay for a bilateral knee arthroplasty. You say that these codes are payable. The Plan
denied your request. The Plan says this service was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if a procedure is performed bilaterally and the
HCPCS code descriptor does not state that it is a unilateral or bilateral procedure, report bilateral surgical
procedures on a single claim line with modifier 50 and one unit of service.

We looked at the file and Medicare rules. This bilateral service was incorrectly reported with two units of
service and modifiers RT and LT, rather than one unit with modifier 50. Based on this information, we decided
that Medicare rules for coverage of a bilateral knee arthroplasty have not been met. Therefore, we decided that
the Plan does not have to pay for a bilateral knee arthroplasty (27447-RT, 27447-LT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on October 1, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit under your dental policy.

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 service provided is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on October 1, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing.

You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 genetic testing at issue in this appeal 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 for the genetic
testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) provided on April 15, 2020.

You asked the Plan to pay for neuromuscular stimulator, electronic shock unit. You say that the item is medically necessary. The Plan denied your request. The Plan says they do not feel that the reasonableness of the provided durable medical equipment is established.

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 pay for neuromuscular stimulator, electronic shock unit. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the neuromuscular stimulator was medically reasonable and necessary in this case, as there is insufficient documentation of a credible evaluation and physical examination of the ankles and feet.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular stimulator, electronic shock unit have not been met. Specifically, there is insufficient documentation indicating the medical necessity of this item. This means the item is not covered. Therefore, we decided that the Plan does not have to pay for neuromuscular stimulator, electronic shock unit (E0745) provided on April 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest X-ray provided on September 23, 2020.

You asked the Plan to pay for the chest X-ray. 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 is not a network provider with the Plan. 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 a chest X-ray provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental fillings provided on September 30, 2020.

You asked the Plan to pay for the dental fillings. You say that you would like the fillings paid for. The Plan denied your request. The Plan says you have already received payment for two fillings on September 16, 2020 so the other two exceed the frequency limitation.

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 would exceed the Plan benefit. Therefore, we decided that the Plan does not have to pay for the dental fillings provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination provided on
October 13, 2020.

You asked the Plan to waive the copayment for the radiologic examination. You say that you should not have a
copayment. The Plan denied your request. The Plan says you were charged this copayment correctly as the
copay waiver applies to the office visit.

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
copayment for Outpatient Basic Radiological Services.

You have been asked to pay a $20 copayment for the radiologic examination. The radiologic examination falls
within the Outpatient Basic Radiological Services at primary care physician's office visit 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 radiologic examination provided on October 13, 2020.