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

We decided that the Plan does not haveto pre-approveTekturna 150mg tablet for the enrollee.You asked the Planto pre-approvethe tablet. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is usually self-administered by patients.The Plan must follow Medicare rules. Therules 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-approveTekturna 150mg tablet for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services (CPT codes 97035 and 97140) for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pre-approve chiropractic services (CPT codes 97035 and 97140) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the allergy injections provided from September 25, 2019 and October 21, 2019.You asked the Plan to waive the copayment for the allergy injections. You say that you were never told that you would have a $40 copayment for your allergy injections. 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 $40 copayment for in-network specialist services (including surgery second opinion and telehealth or urgently needed services). You have been asked to pay a $40 copayment for the allergy injections on each date of service. The allergy injections fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the allergy injections are considered a physician 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 for the allergy injections provided from September 25, 2019 and October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forspecialist services. You say that you were not told that this provider was not in-network and would like for this appointmentto be covered as though it were in-network.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.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 medical services provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNexium.You asked the Plan to pre-approveNexium. The Plan denied your request. The Plan says a self-administered drug is not covered under the enrollee's Part B 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 pre-approveNexium.Benefits for Nexiummay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits andappeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite for 3 surfaces on an anterior tooth (D2332) and the resin-based composite on 4 or more surfaces of an anterior tooth (D2335) provided on November 26, 2019.You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says fillings are not 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, resin based composites are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the resin-based composite for 3 surfaces on an anterior tooth (D2332) and the resin-based composite on 4 or more surfaces of an anterior tooth (D2335) provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on November 14, 2019 and November 21, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on November 14, 2019. The allowed amount is $825 and 20% of that is $165. You received a Medicare Part B drug on November 21, 2019.The allowed amount is $825 and 20% of that is $165.The total amount you owe is: $330. You have been asked to pay the total coinsurance amount of $330for a Medicare Part B drug. A Medicare Part B drug 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 fora Medicare Part B drug provided on November 14, 2019 and November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 4, 2019.
You asked the Plan to pay for the dental service. You say that you have pre-periodontal disease. You say that your provider recommends that your teeth be examined and treated every quarter. You say that this has been successful so far. You also say that if this treatment plan were not completed, your stable condition would not be maintained. The Plan denied your request. The Plan says prophylaxis is covered twice per year. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and prophylaxis is a covered service, the frequency limit of 2 prophylaxis per year has been exhausted. The record shows that the Plan paid for prophylaxis that you received on May 21, 2019 and August 26, 2019. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on December 4, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for Skilled Nursing Facility (SNF) service provided from October 27, 2019 to October 31, 2019.
You asked the Plan to pay for SNF service. You say that you are a valid provider for Medicare. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because no valid Medicare identification was submitted by the provider.
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 most current information from the Centers for Medicare and Medicaid Service (CMS) shows that the CMS Certification Number (CCN) for this provider has no associated expiration date and was effective for these dates of service. As such, we find that the Plan's denial based on no valid Medicare CMS Certification Number (CCN) is not supported. Therefore, we decided that the Plan has to pay for Skilled Nursing Facility (SNF) service provided from October 27, 2019 to October 31, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain (70551).
You asked the Plan to pre-approve an MRI of the brain. You say that the service is 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 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 an MRI of the brain. Our reviewer says that the service is not medically necessary. Our physician reviewer found there is no evidence of intractable headache or neurologic symptoms. There is no documentation of a plan to perform an MRI or any thought process as to why the test is needed. As such, the requested MRI is not shown to be currently medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain (70551).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you had a really bad fall and need a shower chair for safety. The Plan denied your request. The Plan says a shower chair is not medically necessary and is considered a convenience item.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBuprenorphine patches.You asked the Plan to pre-approve Buprenorphine. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveBuprenorphine patches.Benefits for Buprenorphinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 you were vomiting for five days after being discharged from the hospital following your knee surgery. On the date of service, your daughter called 911 and the EMS arrived and took your vitals. You say that you were told by the EMS responders that your vitals were fine and that they did not think you needed to go to the hospital. You say that you were told that you would be in the hospital all day and then they would just send you home. You stated that you took some medication and called your doctor later that day. Your doctor was furious that you were not transported and later you discovered that your pain medication and antibiotics were not agreeing with you. 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, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic imaging service provided on January 15, 2020.You asked the Plan to waive the copayment for the ophthalmic diagnostic imaging test. You say that you already paid a $25 copayment before seeing your doctor.  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 $100 copayment for in-network, outpatient Medicare-covered diagnostic procedures/tests. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $100 copayment for the ophthalmic diagnostic imaging service.You have been asked to pay a $56.31 copayment for the ophthalmic diagnostic imaging test. The ophthalmic diagnostic imaging test 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 for the ophthalmic diagnostic imaging service provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 22, 2019 to enrollee by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 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 medical services provided on October 22, 2019 to enrollee by a non-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant services for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says custodial care is not covered.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. We looked at the file and Medicare rules. The requested services are custodial care. These services are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve attendant services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment for the office visit provided on November 11, 2019.You asked the Plan to reduce the copayment for the office visit. You say that you were informed this was considered an office call. You say that you were informed your copayment was only$5.The Plan denied your request. The Plan says that the $50 copayment applied correctly.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 enrollees must pay $5 for each Medicare-covered visit with an in-network primary care physician. The Plan says you must pay a $50 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than $5 for the office visit.The immediate care clinic is not considered a specialist's office. Therefore, we decided that the Plan has to reduce the copayment for the office visit provided on November 11, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myoelectric arm with independently articulating digits.
You asked the Plan to pre-approve myoelectric arm with independently articulating digits. You say that please consider this for additional information to appeal the decision of denying the enrollee the opportunity at a multi-articulating hand. The Plan denied your request. The Plan says this request does not meet Medicare criteria as reasonable and necessary.
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 myoelectric arm with independently articulating digits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is a convenience item and is not in line with medical standards, which do not generally support myoelectric fingers. There is no indication the enrollee could not safely and adequately function with a lesser device/prosthetic hand. As such, this request is not 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 myoelectric arm with independently articulating digits have not been met. Therefore, we decided that the Plan does not have to pre-approve myoelectric arm with independently articulating digits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 30, 2019 by a non-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 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 medical services provided on October 30, 2019 by a non-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 is currently undergoing treatment at an acute care hospital (ACH) following surgery for an intussusception. The enrollee is not currently intubated/ventilated. 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 the LTACH. 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 long term care (LTC) 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 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.