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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that additional therapy will benefit and strengthen your current status. The Plan denied your request. The Plan says you do not require daily skilled therapy or nursing in an inpatient setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Coflex).You asked the Plan to pre-approve Coflex procedure. You say that studies prove the effectiveness of Coflex.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is not enough evidence that shows this procedure is safe and effective.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 Coflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented spinal instability. Coflex remains experimental at this time. More research is needed to show the safety and efficacy of the Coflex 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 Coflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device (Coflex).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 30, 2019. You asked the Plan to waive the copayment for the colonoscopy. You say that Medicare fully pays for a colonoscopy. You say that you don't understand why you are being billed. 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 $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that polyps were removed during the colonoscopy, which is considered a surgical procedure. 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 colonoscopy provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay this claim for the physician services provided on January 27, 2020 by an out of network (OON) provider. You asked the Plan to pay this claim. You say that these services were medically necessary. 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 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 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 physician services provided on January 27, 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 contact lenses provided March 13, 2019.
You asked the Plan to pay for the contact lenses.. You say that the contact lenses should be covered. The Plan denied your request. The Plan says the eyewear allowance was already exhausted.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $500 a year towards one set of eyewear. We looked at the file and the Plan's rules. The plan already applied the $500 allowance to a pair of eyeglasses purchased within the same calendar year. Based on this information, we decided that the Plan's rules for coverage of the contact lenses. have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses provided March 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Polar Care Circulating Pad provided on December 10, 2019.
You asked the Plan to pay for the Polar Care Circulating Pad. You say that this helped to reduce the swelling and allowed you to keep my scheduled physical therapy appointments. The Plan denied your request. The Plan says that this is not covered.
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pay for the Polar Care Circulating Pad provided on December 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (Denosumab).
You asked the Plan to pre-approve the Prolia. You say that the enrollee has tried and failed bisphosphonates. The Plan denied your request. The Plan says documentation was not received stating that the enrollee has a history of osteoporosis-related fracture, or the enrollee has failed or has a contraindication to Zoledronic Acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Prolia. Our reviewer says that the Prolia (Denosumab) is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the patient has tried and failed the required drug, Zoledronic Acid. Our reviewer found that the provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also found that the provided medical records do not report a history of osteoporotic fracture.
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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (Denosumab).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the nuclear stress test, the medical supply,
the Part B injection, and the stress test provided on November 18, 2019.
You asked the Plan to waive the cost share for the nuclear stress test, the medical supply, the Part B injection
and the stress test. You say that each of these services test your budget and your ability to pay. You say you
would like your share to be taken to $0 or reduced significantly. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75
copayment for each Medicare-covered radiological diagnostic services, 20% coinsurance Medicare-covered
medical supply, 20% coinsurance each Medicare-covered Part B drug, and a $20 copayment for Medicarecovered
non-radiological diagnostic services.
You have been asked to pay a total of $350.72 for the nuclear stress test, the medical supply, the Part B
injection and the stress test. The nuclear stress test, the medical supply, and the stress test fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B injection falls
within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service Service Allowed Amount Copayment/Coinsurance Member
Liability
November 18, 2019 Nuclear stress
test
$1,401.48 $75.00 $75.00
November 18, 2019 Medical supply $1,041.50 20% $208.30
November 18, 2019 Part B
injection
$237.08 20% $47.42
November 18, 2019 Stress test $70.84 $20.00 $20.00
Total $350.72
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 cost share for the nuclear stress test, the medical supply, the Part B
injection, and the stress test provided on November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle-foot orthosis (AFO) rendered on December 19, 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 services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an AFO is covered when specific criteria are met. 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 enrollee has a history of rheumatoid arthritis, diabetes and chronic kidney disease. There are reports of knee and wrist pain but there is no documentation of ankle or foot symptoms in the provided records. The records do not support that the AFO was reasonable and medically necessary for the enrollee. 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 for the ankle-foot orthosis (AFO) rendered on December 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the echocardiography provided on October 22, 2019, the inpatient stay provided from October 31, 2019 through November 5, 2019 and the ambulance transport provided on November 5, 2019.You asked the Plan to waive the cost share for the echocardiography, inpatient stay and ambulance transport. You say that due to your income you cannot afford to pay.The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each Medicare-covered radiological diagnostic service, a $250 copayment each day for days 1 to 5 for Medicare-covered hospital care and a $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a total of $1,583.35 for the echocardiography, inpatient stay and ambulance transport. The echocardiography falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The inpatient stay falls within the "Inpatient Hospital Care" benefit category. The ambulance transport falls within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost share for the echocardiography provided on October 22, 2019, the inpatient stay provided from October 31, 2019 through November 5, 2019 and the ambulance transport provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.You asked the Plan to pre-approve the compression stockings. You say that without the compression stockings your legs will swell up to the point that you cannot use them and they will continue to swell.The Plan denied your request. The Plan says this item is not a covered benefit under Medicare or the Plan.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on September 9, 2019 by an out-of-network provider.You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says they received a signed treatment plan from your dentist, which indicates you acknowledged and accepted financial responsibility prior to  receiving the dental 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.The provider is not in-network and your EOC clearly states, you must visit a participating dental network provider to receive dental benefits.Therefore, we decided that the Plan does not have to pay for the dental services provided on September 9, 2019 by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine vision services provided on September 27, 2019 by an out-of-network provider.
You asked the Plan to pay for routine vision services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says no prior authorization was obtained by the provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The provider is not in-network and your EOC clearly states, supplemental (i.e., routine) vision services must be received from a participating provider in order to be covered by the plan. Therefore, we decided that the Plan does not have to pay for routine vision services provided on September 27, 2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit infusions.
You asked the Plan to pre-approve the Retacrit treatments. You say that this treatment is needed for the enrollee's anemia. The Plan denied your request. The Plan says the enrollee's lab values do not show anemia severe enough to require this treatment.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Retacrit treatments. Our reviewer says that the requested use of Retacrit is not considered reasonable and necessary for this enrollee. Our physician reviewer found the request is for Retacrit for symptomatic anemia from chronic kidney disease. In order to initiate Retacrit, the hemoglobin should be less than 10. On initial consultation, the hemoglobin was 10.9 and on most recent labs on 3/23/20, the hemoglobin was normal at 12.2. The service is 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 the Retacrit treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit infusions.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the ambulance was contacted outside of your primary care provider's office because of a severe drop in your blood sugar levels. You say that it was a life or death situation and when the paramedics arrived they were able to treat you and stabilize your blood sugar levels. You stated that since you were stable you did not require transport and decided you would follow up with your primary care physician. 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 November 9, 2019. 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 for the ambulance services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on January 10, 2020 by an innetwork
provider.
You asked the Plan to pay for the dental services. You say that you feel this denied incorrectly. The Plan
denied your request. The Plan says this is a duplicate of another claim that has already been paid.
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.
You are responsible for 50% of the charges for tooth extractions. The claim denied correctly as a duplicate as it
processed and paid correctly under another claim. The provider charged $160 for the extraction leaving you
responsible for the $80 copayment. Therefore, we decided that the Plan does not have to pay for the dental
services provided on January 10, 2020 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen supplies (E1390) provided December 13 to December 31, 2019.You asked the Plan to waive the coinsurance for the oxygen supplies. You say that the coinsurance should be waived because you only had the oxygen concentrator 3 days.The Plan denied your request. The Plan says the correct cost sharing was 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 20% coinsurance for Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the oxygen supplies. The oxygen supplies fall within the Durable Medical Equipment 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 for oxygen supplies (E1390) provided December 13 to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on November 26, 2019 by an out of network (OON) provider.
You asked the Plan to pay for nursing facility care. You say that these were medically necessary services provided in good faith. The Plan denied your request. The Plan says these 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 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 nursing facility care (99309) provided on November 26, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on September 11, 2019.
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the Plan should pay this claim. The
Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed
the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that there must be information in the patient's
medical record that supports the medical necessity for the item.
We looked at the file and Medicare rules. The records do not contain a face-to-face encounter supporting that
the enrollee was evaluated or treated for a condition that supports the orthoses. Based on this information, we
decided that Medicare rules for coverage of the ankle foot orthosis (L1971) have not been met. Therefore, we
decided that the Plan does not have to pay for the ankle foot orthosis provided on September 11, 2019.