Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a folding walker and a commode provided on January 4, 2020.You asked the Plan to reimburse you for the folding walker and commode. The Plan denied your request. The Plan says the service sought or obtained was rendered by a provider who is not under contract with the Plan.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. A supplier means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.We looked at the file and Medicare rules. The folding walker and commode were provided by an entity other than a provider that furnishes health care services under Medicare and is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for a folding walker and a commode provided on January 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revlimid for the enrollee.
You asked the Plan to pre-approve Revlimid. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Revlimid for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 4, 2019 to June 5, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary.The Plan denied your request. The Plan says an inpatient admission was not necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee was admitted for a skin-sparing left mastectomy with immediate breast reconstruction. Post-operatively she had mild to moderate incisional pain.t. The following day her pain was controlled with Extra-Strength Tylenol, and she was discharged home with outpatient follow-up. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay forthe acute inpatient hospital care provided from June 4, 2019 to June 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the laboratory services provided on
December 10, 2019.
You asked the Plan to waive the deductible for the laboratory services. You say that you should not be charged
twice for the laboratory services. 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. Your
contract with the Plan says that there is a $300 in-network deductible that applies towards in-network
laboratory services.
The laboratory services you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is a $300 in-network deductible that applies towards in-network laboratory
services. The allowed amount for the laboratory services is $11.74. Therefore, $11.74 is the amount that is
applied to your deductible.
This cost sharing is a contractual obligation that had not been met at the time the laboratory services was
received on December 10, 2019. Therefore, we decided that the Plan does not have to waive the deductible for
laboratory services provided on December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 11, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says no prior authorization was obtained for the services rendered.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 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 services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on February 3, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that this was a pre-operative visit and you should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for specialist visits. You hada specialist visit on February 3, 2020. Pre-operative visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls withinthe physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on February 3, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pay forthe nursing facility care(99309) provided on April 19, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON nursing facility care. You say that you do not choose the patients you care for.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 forthe nursing facility care(99309) provided on April19, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec Tablets.You asked the Plan to pre-approve the Nurtec Tablets. You say that the member has tried several medications, but you would like to start them on NurtecTablets for abortive therapy. The Plan denied your request. The Plan says this request is not covered under the member's Medicare Part B benefits because Nurtec is a drug that is taken orally.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 Nurtec Tablets.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Monovisc and Orthovisc (Hyaluronic acid) or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided May 16, 2019 to May 22, 2019.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says that the copayment has been applied correctly to the inpatient hospital care provided.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 $250 copayment per day, for days 1-7 for inpatient hospital care. You have been asked to pay a $1500 copayment ($250 x 6 days) for inpatient hospital care.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 hospital care provided May 16, 2019 to May 22, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe laboratory services rendered on January 28, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the claim was not billed correctly; however, there is no further explanation as to why the claim was incorrect. The Plan has not provided any further documentation or Medicare rules to support that the claim is not payable as billed.Therefore, we decided that the Plan has to pay forthe laboratory services rendered on January 28, 2019.If the Plan does 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 does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysat the present time, the enrollee's care is ongoing, and the current amount of therapy is appropriate to meet their needs.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 fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Ourphysician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. A less intensive, longer duration of therapy may be more appropriate.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing services.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain his condition or prevent deterioration. He has had prior nursing instruction on medication and disease management and has caregiver support. His needs do not require the professional skills of a nurse for ongoing care. Home health skilled nursing services are 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency care provided on
January 25, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial as the services provided were medically necessary and should be assessed as inpatient hospital care. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the emergency care provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. The enrollee has been asked to pay a $90 copayment for the emergency care provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan as the enrollee was not admitted to inpatient status after the emergency services were rendered. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency care provided on January 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray and extraction provided by an OON dentist on January 6, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray and extraction. You say that you called the provider's office and they said that they do accept your insurance.The Plan denied your request. The Plan says this dentist is an out-of-network provider. The Plan also says that prior authorization was not obtained.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray and extraction provided by an OON dentist on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on January 13, 2020.
You asked the Plan to pay for the nurse practitioner service. 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 nurse practitioner 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 nurse practitioner services provided on January 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay foreye surgery (66984) and anesthesia (00142) provided on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forOON eye surgery and anesthesia. You say that you did not know this provider was not in-network.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 foreye surgery (66984) and anesthesia (00142) provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 29, 2019.You asked the Plan to waive the copayment for the ultrasound. You say that your ultrasound has been fully covered in the past. You say that you should be reimbursed.The Plan denied your request. The Plan says the copayment applied correctly.The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $100 copayment per visit for outpatient hospital services. Covered services include x-rays and other radiology services billed by the hospital.You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient hospital 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 ultrasound provided on August 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission.
You asked the Plan to pre-approve inpatient admission. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 inpatient admission. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee had been stable since April 23, 2020 for discharge to home or memory care facility with home health referral and outpatient follow up. It was determined that the enrollee had been medically stabilized with stable vital signs, no significant pain issues, and was at a high level of mobility such that hospital level (observation or inpatient) was no longer medically reasonable or necessary. The enrollee had been referred for home health nursing services and for use of a 30- day cardiac event monitor to determine any next steps in cardiac treatment recommendations, as well as follow up appointment with the Internal Medicine clinic. The review has determined that hospital level of care services after April 23, 2020 were not medically reasonable and 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission.