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

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve the physician's services. You say that believe the in-network provider was very unprofessional and made you uncomfortable. You say that would like to see the out-of-network provider because you would prefer a female physician for treatment of your private lower extremities. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the Plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.

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 female network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eyewear provided .You asked the Plan to pay forthe eyewear. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says eyewear is not covered under the Plan's supplemental vision benefit when provided by an out-of-network optical facility.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided at a network optical facility.We looked at the file and the Plan's rules. The file shows that you self-referred and purchased eyewear at an out-of-network optical facility. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met.Therefore, we decided that the Plan does not have to pay forthe eyewear provided
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordental services (CPT 00431, CPT 04921, CPT 09630) received .You asked the Planto pay forthe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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.Therefore, we decided that the Plandoes not haveto pay fordental services (CPT 00431, CPT 04921, CPT 09630) received .
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay foroutpatient observation services provided to theenrollee.You asked the Plan to pay forthe services. You say that this is medically necessary.The Plan denied your request. The Plan says that in only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.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 pay for the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee was stable and appropriate for observation level of care services after the emergency room evaluation. The review indicates that the services at issue in this case were 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 services have been met.Therefore, we decided that the Plan has to pay foroutpatient observation services provided to the enrollee.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided .You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment 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 . 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 forthe ambulance services provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinjection; single tendon sheath, or ligament (20550) provided You asked the Plan to waive the copayment foran injection. You say that you did not know that you would have to pay this amount.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 $100 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $100 copayment for an injection. The service at issue falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 whenyou enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forinjection; single tendon sheath, or ligament (20550) provided
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forabdominal aortic aneurysm screening (CPT code 76706) provided.You asked the Plan to pay forthe screening. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exhausted your benefit.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Per your benefits in the 2020 EOC, you can only get an abdominal aortic aneurysm screening performed one-time (once per lifetime). You received abdominal aortic aneurysm screening ; therefore, the claim for date of service, denied correctly and you are responsible for the full cost of the abdominal aortic aneurysm screening.Therefore, we decided that the Plan does not have to pay forabdominal aortic aneurysm screening (CPT code 76706) provided
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay forCOVID-19 testing received .You asked the Planto pay forthe testing. You say that you thought that this would be covered at no cost toyou.The Plandenied your request. The Plansaysthattesting for employment screening, public screening, student screening, and travel screening are not covered benefits.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 has not substantiated their denial. There is nothing in the Evidence of Coverage to show that COVID-19 testing for travel purposes is not a covered benefit for members.Therefore, we decided that the Planhas to pay forCOVID-19 testing received .If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic imaging (92134), surgical (67028) and injection drug (J0178) services provided by an out of network (OON) provider.You asked the Plan to pay forthe diagnostic imaging, surgical and injection drug services. You say that you did not realize you did not have coverage for out-of-network services because the Plan had paid for them before.The Plan denied your request. The Plan says that generally services are not covered out of network, but some services may have coverage through your Point-of-Service (POS) portion of the benefit. There is a POS benefit coverage limit for out-of-network services of $5,000 per year. Once this limit is reached, you are responsible for 100% of the cost for any out-of-network 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 an out-of-network benefit limit of $5,000 per year.The requested provider in this case is not a network provider with the Plan. At the time of the services in question, you had met your $5,000 limit for out-of-network benefits. 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 diagnostic imaging (92134), surgical (67028) and injection drug (J0178) services providedby an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided.You asked the Plan to pay forthe lumbar-sacral orthosis. You say that the item was medically necessary.The Plan denied your request. The Plan says there is no evidence prescribing physician ever saw member.The Plan follows Medicare rules. Medicare rules say that the spinal orthosis is covered when Medicare criteria as cited in the Medicare rules section is met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the backWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis (L0650) provided
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy programprovided in an IRF.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 Plan does not have to pre-approveacute IRF admission and services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for choledocholithiasis, pancreatitis and aspiration pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefitfrom the intensive rehabilitation therapy program provided in an IRF.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 Plan does not have to pre-approveacute IRF admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysician services to be provided by an out of network (OON)provider.You asked the Plan to pre-approvephysician services. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says they have approved one visit with the out of network physician to help the enrollee transition to 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-approvephysician services to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe magnetic resonance imaging (MRI) of the brain stem (70553) provided , and the MRI of the abdomen (74183) provided You asked the Plan to waive the copayment forthe MRIs. You say that you were asked to pay only $75 at the time of service and were billed for the additional amount later. You do not think you should be responsible for the amount billed after the service, and that your full paymentresponsibility should be due at the time of service.The Plan denied your request. The Plan says the $150 copayment for each of these services was applied correctly. Information about your copayment responsibility is available to you in the benefits chart of your Plan's contract.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 $150 copayment for diagnostic radiology procedures. You have been asked to pay a $150 copayment for the MRIs. MRIs fall within the diagnostic radiology procedures 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 forthe magnetic resonance imaging (MRI) of the brain stem (70553) provided, andthe MRI of the abdomen (74183) provided .Your complaint about being billed the remaining cost-share amountfor a service after it is provided is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay additionally forthe eyeglasses purchased .You asked the Plan to pay additionally forthe eyeglasses. You say that you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you purchased an eyeglass frame with trifocal lens and anti-reflective lens coating . The total cost of the eyeglasses was $504. Your benefit of $150 was applied to the purchase, leaving you with a member responsibility of $354.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides a $150 allowance once every 24 months for you to use toward the purchase price of eyewear. If the eyewear you purchase costs more than $150, you pay the difference.We looked at the file and the Plan's rules. The file shows that you purchased an eyeglass frame with trifocal 
lens and anti-reflective coating. The total cost of the eyeglasses was $504. Your benefit of $150 was applied to the purchase, leaving you with a member responsibility of $354.Therefore, we decided that the Plan does not have to pay additionally forthe eyeglasses purchased .
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecombination of atezolizumab, paclitaxel and bevacizumab chemotherapy.You asked the Plan to pre-approvecombination of atezolizumab, paclitaxel and bevacizumab chemotherapy. You say that the requested combination of atezolizumab, paclitaxel and bevacizumab chemotherapy is medically necessary.The Plan denied your request. The Plan says the requested combination of atezolizumab, paclitaxel and bevacizumab chemotherapy is not medically necessary.The Plan must followMedicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 combination of atezolizumab, paclitaxel and bevacizumab chemotherapy. Our reviewer says that the requested combination of atezolizumab, paclitaxel and bevacizumab chemotherapy is not medically necessary. Our physician reviewer found the enrollee is diagnosed with non-small cell lung cancer. Per NCCN compendia, tecentriq cannot be approved without knowing if molecular markers EGFR and ALK are wildtype. The request is not medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of combination of atezolizumab, paclitaxel and bevacizumab chemotherapy have not been met.Therefore, we decided that the Plan does not have to pre-approvecombination of atezolizumab, paclitaxel and bevacizumab chemotherapy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound provided .You asked the Plan to waive the copayment forthe ultrasound. You say that you feel you should not beresponsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received an ultrasound on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 youmust pay a $110 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound . You have been asked to pay an $86.30 copayment for the ultrasound, which is less than the contracted $110 copayment amount. The ultrasound falls within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharingis 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 forthe ultrasound provided