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

We decided that the Plan does not have to waive the copayment for emergency care provided on October 27, 2020.
You asked the Plan to waive the copayment for emergency care. You say that you waited in the lobby and did not see anybody. The Plan denied your request. The Plan says you were charged this copayment 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for emergency care. The record shows you had laboratory services and some emergency care services. Emergency care 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 for emergency care provided on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the inpatient hospital stay (99285) provided at an out-of-network (OON) hospital from October 2, 2020, to October 19, 2020.
You asked the Plan to waive the coinsurance for the OON inpatient hospital stay. You say that you were not aware that you could not go to any hospital for an in-network cost-share. The Plan denied your request. The Plan says the coinsurance 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 50% of the total cost per stay for Medicare-covered services provided at an OON hospital. You have been asked to pay a total of $5388.55 ($10,777.10 total Plan allowed amount x 50% coinsurance) for the inpatient hospital stay. the inpatient hospital stay 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 coinsurance for the inpatient hospital stay (99285) provided at an out-of-network (OON) hospital from October 2, 2020, to October 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network vision services provided on September 8, 2020.
You asked the Plan to pay for out of network vision services. You say that you chose this provider because he was two minutes from your home. The Plan denied your request. The Plan says you did not have prior authorization for out of network vision services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 had network providers available who could have provided the vision services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these vision services. Therefore, we decided that the Plan does not have to pay for out of network vision services provided on September 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 22, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.
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
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 services provided on October 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from July 27, 2020,
through August 27, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says nonemergent,
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
physical therapy 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 physical therapy services provided from July 27,
2020, through August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health venipuncture services.
You asked the Plan to pay for the home health venipuncture services. You say that you would like reconsideration because the member is at high risk for severe illness if they develop COVID-19, therefore this service would be beneficial. The Plan denied your request. The Plan says the records do not show that the member has other skilled needs to necessitate Home Health services.
The Plan must follow Medicare rules. Medicare rules say that venipuncture for the purposes of obtaining a blood sample can no longer be the sole reason for Medicare home health eligibility. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health venipuncture services have not been met. Specifically, this service can no longer be the sole reason for home health eligibility. Therefore, we decided that the Plan does not have to pay for the home health venipuncture services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) of the lumbar spine with contrast material (72158).
You asked the Plan to pre-approve the MRI with contrast material. You say that this service is medically necessary. The Plan denied your request. The Plan says a test with contrast material (dye) is not medically necessary based on the enrollee's medical records.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 MRI with contrast material. Our reviewer says that this MRI with contrast is not medically necessary. Our physician reviewer found that the enrollee has sciatica that has been slowly worsening over a few weeks and is radiating to the foot. An MRI of the lumbar spine, with and without contrast material, was requested. An MRI without contrast is standard workup for radiculopathy and appears to be warranted based on the progression of the symptoms. However, contrast material is not supported in the notes and would not lead to improved outcome. Therefore, this request for MRI with contrast will be considered not medically necessary as requested. 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 MRI with contrast material have not been met. Therefore, we decided that the Plan does not have to pre-approve a Magnetic Resonance Imaging (MRI) of the lumbar spine with contrast material (72158).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the collagenase (Xiaflex) injection (J0775) provided on August 31, 2020.
You asked the Plan to waive the coinsurance for the drug injection. You say that you do not feel you should have to pay this bill because you never received an explanation of benefits (EOB). The Plan denied your request. The Plan says Medicare Part B drug services require 20% coinsurance.
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 Medicare Part B prescription drugs. You have been asked to pay $912.60 for the drug injection. The Plan's allowed amount for the drug injection is $4,563 ($4,563 x 20% = $912.60). The cost-sharing information can be found in the Plan's EOC. A collagenase injection falls within the Medicare Part B prescription drugs 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 the collagenase (Xiaflex) injection (J0775) provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental fillings rendered on September 23, 2020.
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 exceed the benefit limit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two fillings per calendar year. We looked at the file and the Plan's rules. The file shows that you received two fillings on February 20, 2020 that the Plan covered. The fillings on September 23, 2020 exceeded the limit of two procedures per calendar year. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the dental fillings rendered on September 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 23, 2020.
You asked the Plan to pay for the ambulance services. You say that your mother had fallen and there was an ambulance crew already on site at her residence. The head nurse called for them to assist her getting back up and treat her in place. 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 23, 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 for the ambulance services provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network podiatrist for the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a treatment plan that requires further continued care from the requested 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 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 a referral to an out-of-network podiatrist for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an all lower extremity prosthesis, flex-walk system or equal (L5981).
You asked the Plan to pre-approve this item. You say that this item is medically necessary. The Plan denied your request. The Plan says there is no clinical documentation from the physician or therapist to corroborate the vendor's claim that you require this item.
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 this item. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation provided does not reveal the treating physician documentation of a K3 level ambulation, therefore the requested item exceeds your medical needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pre-approve an all lower extremity prosthesis, flex-walk system or equal (L5981).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all
four quadrants.
You asked the Plan to pre-approve the dental services. You say that the services were denied as not covered.
You say that these services are in fact a covered benefit. You also say that you believe that the services were
denied in error. The Plan denied your request. The Plan says periodontal scaling and root planing is not a
covered service.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and
root planing (D4341) for all four quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the abutment supported crown (D6058 x 3) and the surgical
placement of an implant body (D6010) provided on September 1, 2020.
You asked the Plan to pay for the dental services. You say that you had an old 3-tooth bridge that fell out. You
say that your dentist advised that the tooth could not be reattached due to the condition that the teeth were in.
You say that you understand that implants are not covered. You also say that you thought the plan would cover
the portion of the cost that would have been charged, had you not chosen the implant alternative. The Plan
denied your request. The Plan says abutment supported crown is not listed as a covered service. The Plan also
says that the surgical placement of an implant body 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 dental services that you received
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for
the abutment supported crown (D6058 x 3) and the surgical placement of an implant body (D6010) provided on
September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant (D6010 x 2), bone graft at time of implant placement (D6104 x 2), and implant supported removable denture for endentulous maxillary arch (D6110 x 2).
You asked the Plan to pre-approve the dental services. You say that you have little to no bone on the bottom part of your mouth where your dentures do not fit correctly. You say that you need implants in order for your dentures to fit your mouth correctly. You say that the right side comes loose and you are unable to use the current dentures without implants. You also say that the regular dentures need to be converted into an implant denture to complete the process. The Plan denied your request. The Plan says surgical placement of an endosteal implant is not listed as a covered service. The Plan says that bone graft at time of implant placement is not listed as a covered service. The Plan also says that implant supported removable denture for endentulous maxillary arch is not listed as a covered service either.
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. The Evidence of Coverage clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant (D6010 x 2), bone graft at time of implant placement (D6104 x 2), and implant supported removable denture for endentulous maxillary arch (D6110 x 2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided August 8, 2020, through August 21, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you did not know there would be a copayment applied to the stay. 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 $395 copayment each day for days 1 to 4 for Medicare-covered hospital care. There is a $0 copayment for additional Medicare-covered days. You have been asked to pay a total of $1,580 ($395 copayment x 4 days = $1,580) for the inpatient rehabilitation services. These services fall 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 for the inpatient rehabilitation services provided August 8, 2020, through August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider. The plan will cover an in network provider.
You asked the Plan to pre-approve the pneumatic compression pump. You say that the claim should be paid since the enrollee discontinued use of the basic pump. The Plan denied your request. The Plan says the advanced compression pump (E0652) is available through an in 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 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 medical services to be provided by an out of network (OON) provider. The plan will cover an in network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says services can be safely received in another setting, such as a skilled nursing facility.

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 enrollee appears to be improving and should only require short-term additional acute care services which can safely be administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered soon after treatment has been completed.

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 admission to a long term acute care hospital (LTACH) for the enrollee.