Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services received from February 1, 2019 to November 18, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. 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 pay for chiropractic services received from February 1, 2019 to November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating
hospital on December 2, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that the Plan should pay 80% of the cost.
The Plan denied your request. The Plan says the correct copayment has been 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 $250
copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital.
You have been asked to pay $116.07 which is less than your copayment amount of $250 copayment for a CT
scan. A CT scan falls within the outpatient diagnostic tests/advanced imaging services/outpatient hospital
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 a CT scan provided by a
participating hospital on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 30, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered on April 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix.
You asked the Plan to pre-approve the Granix. You say that the records provided support the need for the drug in dispute. The Plan denied your request. The Plan says the enrollee has not had previous treatment with or an intolerance to Neupogen and Nivestym. The Plan says that the enrollee does not meet the criteria for coverage of the requested drug.
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 Granix. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have newly diagnosed lung cancer, for which he is to start adjuvant chemotherapy. A request has been made for Granix, assumedly to stave off neutropenia, which may be caused by the chemotherapy. The health plan requires that other forms of anti-neutropenic agents be used first. There is no evidence that the enrollee is allergic to or intolerant of these other anti-neutropenic agents. There is no evidence that the enrollee has tried and not responded to these other forms of anti-neutropenic agents. There is no documentation as to why these other forms of anti-neutropenic agents would not be expected to be safe and effective for the enrollee. Therefore, the requested Granix is not shown to be currently medically necessary and 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 the Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation services provided on November 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the psychiatric diagnostic evaluation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON 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 for the psychiatric diagnostic evaluation services provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Mohs surgery provided by a participating physician on December 23, 2019.
You asked the Plan to waive the coinsurance for Mohs surgery. You say that you had this procedure done in a building, not a hospital. The Plan denied your request. The Plan says the correct copayment has been 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 outpatient surgery/in-network/outpatient hospital services/all other services. You have been asked to pay a 20% coinsurance of the allowed amount for Mohs surgery. The total allowed amount is $2,893.67. The total amount you are being asked to pay is $578.73 ($2,893.67 x 20% = $578.73). When a hospital owns an outpatient facility, an outpatient hospital facility coinsurance is applied; therefore, the correct coinsurance has been applied. Mohs surgery falls within the outpatient surgery/in-network/outpatient hospital services/all other 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 coinsurance for Mohs surgery provided by a participating physician on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray and endodontic therapy provided on December 9, 2019 and December 11, 2019.
You asked the Plan to pay for the additional intraoral periapical x-ray and endodontic therapy. You say that you were told that there would be no charge for the exam and x-rays because you were referred by your general dentist. You also say that the office representative who helped you was never told that the Plan only paid for one root canal per year. The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitations had 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, intraoral x-rays and root canals are each limited to one procedure per calendar year. The record shows that you received two intraoral x-rays on December 9, 2019, one of which was paid by the Plan, and your intraoral x-rays benefit was then exhausted. The record also shows that you received two root canals on December 11, 2019, one of which was paid by the Plan, and your root canals benefit was then exhausted. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray and endodontic therapy provided on December 9, 2019 and December 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from April 24, 2019 through September 9, 2019.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the procedure was not pre-certified. 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 psychotherapy 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 psychotherapy services provided from April 24, 2019 through September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services and specialist services rendered from August 24, 2019 to August 25, 2019.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $400 copayment per stay for outpatient observation stays and a $40 copayment for specialist services.
The file shows that you received outpatient hospital services from August 24, 2019 to August 25, 2019. You have been asked to pay a $400 copayment for these services. These services fall within the outpatient observation stays 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.
The file shows that you received specialist services from August 24, 2019 to August 25, 2019. You have been asked to pay a $40 copayment for these services. These services fall within the specialist 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 outpatient hospital services and specialist services rendered from August 24, 2019 to August 25, 2019.
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 told by the ambulance responders
at the time of the incident that you would not be billed. You say that you feel the charges are too much for the
services that were provided. 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 January 30, 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the outpatient hospital services rendered on January 9, 2020.
You asked the Plan to waive the deductible for these services. You say that you were not informed that there would be a deductible. The Plan denied your request. The Plan says the deductible was 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 there is $750 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the outpatient hospital services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 9, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the outpatient hospital services rendered on January 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF care. You say that you are unable to care for yourself. The Plan denied your request. The Plan says there is not a skilled care need and that the criteria for SNF care haven not been met.
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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was treated for pain. The enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was dependent for transfers and non-ambulatory services. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs or skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on
November 16, 2019 and December 4, 2019.
You asked the Plan to waive the copayment for the ambulance services. You say that the ambulance services
were absolutely medically necessary. The Plan denied your request. The Plan says you were charged this cost
sharing 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 $290
copayment for each ambulance trip in-network or out-of-network. You had 3 ambulance trips. The Plan
charged you $870 for these services. 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 ambulance
services provided on November 16, 2019 and December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair and accessories to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the power wheelchair and accessories. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network providers available to the enrollee that can provide the items being requested, such as Numotion.
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 power wheelchair and accessories to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for SNF services are not met.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there are no identifiable skilled nursing service needs. The records do not show you require skilled nursing or therapy services daily. Your condition 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan does not have to pre-approve total hip replacement for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the BMI is above the recommended level.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with progressively worsening grade 8/10 left hip and anterior groin pain with mechanical symptoms of catching and locking. Significant functional limitations are noted in ambulatory tolerance and activities of daily living. Clinical exam findings are consistent with radiographic evidence of severe left hip osteoarthritis with obliteration of the joint space, subchondral sclerosis, and osteophyte formation. The enrollee has failed to improve with activity modification, medications, ambulatory assist device, and home exercise. The enrollee has an elevated body mass index (44.3) and has reportedly been unable to lose weight with diet alone. Under consideration is a request for left total hip replacement. Current evidence based medical literature supports total hip replacement in this enrollee's clinical setting and indicates that obesity in itself should not be a deterrent to undergoing total hip replacement to relieve symptoms. Therefore, in this reviewer's opinion, the request for left total hip replacement is 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 the surgery have been met. Therefore, we decided that the Plan does not have to pre-approve total hip replacement for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Morphine Sulfate tablets.
You asked the Plan to pre-approve Morphine Sulfate tablets. You say that Morphine Sulfate tablets are medically necessary. The Plan denied your request. The Plan says Morphine Sulfate tablets are not covered under Medicare 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 Morphine Sulfate tablets.
Benefits for Morphine Sulfate tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.