Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided
on September 1, 2020.
You asked the Plan to pay for the core buildup. You say that the office you are seen at requires you to pay for
the service the same day as it is provided. You also say that you would like the Plan to alleviate you from
having to pay the entire bill. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core
buildup, including any pins when required provided on September 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital care provided from June 22, 2020, to July 1, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that you would like this copayment waived.The Plan denied your request. The Plan says the copayment applied directly in this case.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 $200 copayment per day for days 1-4 and a 0$ copayment for days 5-90 for inpatient hospital care. You have been asked to pay a total cost share of $800 for the ninedays of inpatient care (fourdays x $200 copayment+ 0$ copayment for additional days). The services received falls within the inpatient hospital 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 forthe inpatient hospital care provided from June 22, 2020, to July 1, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation.You asked the Plan to pre-approvethe additional routine transportation. You say that you would like reconsideration because the member has a condition which requires many appointments.The Plan denied your request. The Plan says the member has used their 24 allowed trips.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approveadditional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveBelbuca 150mg MCG film for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare 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 Plandoes not haveto pre-approveBelbuca 150mg MCG film for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endodontic procedure (D3999).
You asked the Plan to pre-approve the endodontic procedure. The Plan denied your request. The Plan says this
service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
endodontic procedure (D3999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you believe that LTACH care is appropriate in this case.The Plan denied your request. The Plan says LTACH care is not needed when continued care in the short-term facility is available.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 the patient is currently undergoing treatment at an ACH for COVID-19.His hospital stay has been complicated by multiple cardiac arrests and renal failure.The enrollee was intubated/ventilated and subsequently received a tracheotomy.The enrolleehas been weaned from the ventilator.There is no evidence that the enrollee requires services that are not currently available.As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to theLTACH.The enrollee can remain at the current ACH until such time no acute services are required.The enrollee can then be transferred/discharged to a lower level of care for any ongoing needs.We looked at this physician's review, the file, and Medicarerules. 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-approvelong term acute care hospital (LTACH) services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 6 occupational therapy visits.
You asked the Plan to pre-approve 6 occupational therapy visits. You say that the services are medically necessary. The Plan denied your request. The Plan says additional home health services are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 6 occupational therapy visits. Our reviewer says that the services requested are not medically necessary. Our physician reviewer found you do not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbation of chronic medical problems or hospitalizations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from July 2, 2020, to July 4, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you were taken to the hospital for hyperglycemia.The Plan denied your request. The Plan says self-administered drugs are not covered services under your plan.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 pay forthe self-administered drugs provided from July 2, 2020, to July 4, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe 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 for outpatient hospital services provided on July 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient hospital services. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services were not emergent.
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 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 outpatient hospital services provided on July 10, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea whirlpool tub.You asked the Plan to pre-approvea whirlpool tub. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.The Plan must follow Medicare rules. The rules say that for Whirlpool Bath Equipment is covered if the enrollee is homeboundThe requested item is only covered when the enrollee is homebound. Review of the filedoes not support that the enrollee is homebound.Therefore, we decided that the Plan does not have to pre-approvea whirlpool tub.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound provided on August 11, 2020.You asked the Plan to waive the copayment forthe ultrasound. You saythat they insisted you get more tests after your mammogram. You say that this should be covered by your insurance benefits.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 $50 copayment for diagnostic procedures and tests at an in-network specialist's office.You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The ultrasound is considered a diagnostic service. 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 ultrasound provided on August 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on August 10, 2020.You asked the Plan to waive the copayment forlaboratory services. You say that your doctor does not have the ability to do the bloodwork at his office. You say that the copayment should be paid.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 $40 copaymentfor each Medicare-covered laboratory test in an in-network outpatient hospital facility. You have been asked to pay a $40 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were provided 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 youagreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory services provided on August 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe echocardiographyprovided on August 19, 2020.You asked the Plan to waive the copayment forthe echocardiography. You say that more people would go for tests if copayments went away.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 $100 copayment for each Medicare-covered diagnostic procedure and test in an outpatient hospital facility.You have been asked to pay a $100 copayment for the echocardiography. The echocardiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe echocardiography provided on August 19, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that these items are necessary for you.The Plan denied your request. The Plan says that these items are not covered.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the in network rate forthe oral exam (D0120) and bitewing x-rays (D0274) provided on July 10, 2020.You asked the Plan to pay the in network rate forthe dental services. You say that you do not agree with the member responsibility on this claim. You say that you have a medical condition which requires you to be monitored during dental procedures. You say that this means that you have to go to an out of network provider. You also say that you would like this claim to be reprocessed and paid.The Plan denied your request.The Plan says the provider in this case is out of network. The Plan says when you receive services out of network, the coinsurance level will apply to the average negotiated in-network fee schedule (INFS) in your area. The Plan also says that you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist.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, there is 50% coinsurance for preventive and diagnostic dental services that you receive out of network. The Evidence of Coverage clearly states that you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist.Therefore, we decided that the Plan does not have to pay the in network rate forthe oral exam (D0120) and bitewing x-rays (D0274) provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forinpatient mental health provided on June 15, 2020, through June 22, 2020.You asked the Plan to pay forinpatient psychiatric hospital services. You say that the services rendered were medically necessary.The Plan denied your request. The Plan says that there is no evidence that the member's treatment could not be met at a less restrictive, outpatient level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the service is medically necessary. Our physician reviewer found that the enrollee did require inpatient mental health treatment as he was a danger to himself. Active treatment was taking place under the supervision of a physician and the services were reasonably expected to improve the patient's condition. Based upon review of the records provided, the admission of this patient does meet the criteria for acute inpatient mental health treatment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Specifically, the enrollee does require active treatment that is believed to improve his condition.Therefore, we decided that the Plan has to pay forinpatient mental health provided on June 15, 2020, through June 22, 2020.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from July 7, 2020, to July 15, 2020.
You asked the Plan to pay for the medical services. You say that the enrollee no longer had hospice services
during the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for
coverage of Part B benefits starting on the date of hospice 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. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on July 7, 2020. The services in question were provided before
the end of that month. Therefore, we decided that the Plan does not have to pay for the medical services
provided from July 7, 2020, to July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on October 28, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that GeneSight testing may only be ordered by licensed psychiatrists or neuropsychiatrists. We looked at the file and Medicare rules. The file shows that the testing was not ordered by a licensed psychiatrist or neuropsychiatrist. 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 for the GeneSight Psychotropic Assay rendered on October 28, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGenvisc 850 injections.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the enrollee does not have a history of failure, contraindication, or intoleranceto Synvisc, Synvisc-One, Durolane, or Gelsyn-3.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 the requested services. Our physician reviewer found that the enrollee has osteoarthritis of the knees confirmed by radiologic evidence. She has ongoing knee pain that interferes with daily activities,and has failed at least three months of conservative therapy. The Plan requires a trial of Synvisc, Synvisc-One, Durolane, or Gelsyn-3 before they will approve the requested drug. In this case, theenrolleehas not triedand failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective, or likely have adverse effects for the enrollee.
We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approveGenvisc 850 injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) with quantitative coronary calcium services.You asked the Plan to pre-approveCT with quantitative coronary calcium services.. You say that you would like the plan to reconsider their denial.The Plan deniedyour request. The Plan says the requested services 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 CT with quantitative coronary calcium services at issue in this appeal is being 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 pre-approvecomputed tomography (CT) with quantitative coronary calcium services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered.

You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is 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 test at issue in this appeal, a cardiovascular risk assessment panel, 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 laboratory services rendered.