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

We decided that the Plan does not have to waive the copayment forthe low dose CT scan provided by"the provider" on September 3, 2019.You asked the Plan to waive the copayment forthe low dose CT scan. You say that you feel this should fall under the preventive category.The Plan denied your request. The Plan says the claim has been processed correctly per your plan benefits.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 $225 copayment for Medicare-covered diagnostic radiology services. Review of the file shows that while this service is covered at no copayment charge for screening purposes, the test was requested due to lung nodules being present. Therefore, this testing was not provided for screening purposes. You have been asked to pay a $225 copayment for the low dose CT scan. The low dose CT scan 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 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 low dose CT scan provided by "the provider" on September 3, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visits provided on August 18, 2019 to September 14, 2019..You asked the Plan to pay forthe office visits. You say that you were advised that this provider was in-network.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an out of 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 office visits provided on August 18, 2019 to September 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One.You asked the Plan to pre-approveSynvisc-One. 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 forcertain 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 Synvisc-One. Our reviewer says that Synvisc is not medically reasonable and necessary in this case. The provided medical records do not indicate that you have tried and failed the required drugs or that they would likely be less effective and/or likely have adverse effects for you.Our physician reviewer found that your condition does not meet criteria for Synvisc-One.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore,we decided that the Plan does not have to pre-approveSynvisc-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cervical cancer screening rendered on June 5, 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 the services exceed the benefit limit.The Plan must follow Medicare rules. The rules say that a cervical cancer screening is covered once every two years.We looked at the file and Medicare rules. The file shows that the cervical cancer screening was perofmred on June 5, 2019. The enrollee previously received these services on March 8, 2018 for which the Plan approved 
and paid. The services on June 5, 2019 were performed less than two years from the previously covered services.Therefore, we decided that the Plan does not have to pay forthe cervical cancer screening rendered to on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran outpatient office visit and lab testing provided by "the medical center", on June 20, 2019.You asked the Plan to pay forthe outpatient office visit and lab testing. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care 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 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 servicesat 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 foran outpatient office visitand lab testing providedonJune 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACHservices. You say that this is medically necessary.The Plandenied your request. The Plansaysthe information supports the current acute care setting.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 andnecessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include oxygen supplementation with respiratory treatments, surveillance laboratory studies, blood transfusions as indicated, intravenous antibiotics, hemodialusis and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto waive the coinsurance forskilled nursing facility (SNF) care provided by "the provider" from May 10, 2019 to May 20, 2019.You asked the Planto waive the coinsurance forSNF care. You say that the facility only provided SNF care on the last two days.The Plandenied your request. The Plansaysthe medical records show that you received SNF care for the dates of service at issue.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 30% coinsurance for SNF care. You have been asked to pay 30% coinsurance for SNF care.The medical records show that you received SNF care during the dates of service at issue.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 Plandoes not haveto waive the coinsurance forskilled nursing facility (SNF) care provided by"the provider" from May 10, 2019 to May 20, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you fell in the middle of the night and were unresponsive. Your wife called an ambulance and the responders treated and stabilized you. You say that your condition normalized after treatment, and after discussing with the paramedics and your wife, you decided that you did not need to go to the emergency room.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 July 14, 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 forthe ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's services providedon August 20, 2019.You asked the Plan to waive the copayment for the physician's services. The Plan denied your request. The Plan says the claim processed 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 $35 copayment for Medicare covered vision services, specialist's office.You have been asked to pay $35 copaymentfor the physician's services. The physician's services fallwithin the Medicare covered vision 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 physician's services providedon August 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on August 5, 2018.You asked the Plan to reimburse you for the hearing aids.The Plan denied your request. The Plan says the claimwasfiled beyondthetimely filing limit which is no later than 12 months (or 1 full calendar year) after the date when the services were provided.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the hearing aids was not filed until August 27, 2019.This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 5, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services providedon September 9, 2019.You asked the Plan to pay forthe physician's services. 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 servicesat 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 forphysician's services providedon September9, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services for an endoscopy provided onJuly 26, 2019.You asked the Plan to pay forthe physician's services for an endoscopy. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 Plandid not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services.Therefore, we decidedthat the Plan does not have to pay forphysician's services for an endoscopy provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornurse practitioner services provided on August 1, 2019.You asked the Plan to pay forthe nurse practitionerservices. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 and the referring physician are notnetwork providerswith the Plan. The Plan did not pre-approve the servicesat 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 fornursepractitioner services provided on August 1, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve12 hours of neuropsychological testing for "the beneficiary".You asked the Plan to pre-approve12 hours of neuropsychological testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that neuropsychological testing is only covered for certain indications.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 12 hours of neuropsychological testing. Our reviewer says that the documentation does not support that the requested neuropsychological testing is medically reasonable or necessary. Our physician reviewer found the documentation shows that the enrollee had an MRI performed which was found to be unremarkable with no focal pathology. Utilizing the information in the record that this testing is intended to diagnose and characterize the neurocognitive effects of medical disorders that impinge directly on or indirectly on the brain including detection of neurologic disease based on quantitative assessment of neurocognitive abilities, differential diagnosis between psychogenic and neurogenic syndromes, delineation of neurocognitive effects of central nervous system disorders, neurocognitive monitoring of recovery or progression of central nervous system disorders or assessment of neurocognitive function for the formulation of rehabilitation and/or management strategies among individuals with neuropsychiatric disorders. The enrollee does not meet the criteria for neuropsychological testing as there is no individualized treatment plan or expectation of improvement.Review of the file shows that the plan uses Local Coverage Determination LCD L34646 to support their denial. However, LCD L34646 is not valid for the enrollee's state of NY for Medicare Part B.Therefore, we are unable to use LCD L34646 to substantiate our decision.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of 12 hours of neuropsychological testing have not been met.Therefore, we decided that the Plan does not have to pre-approve12 hours of neuropsychological testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveTymlos 80mcg dose pen injector.You asked the Planto pre-approvethe injector. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is a medical only policy with "the 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 Plandoes not haveto pre-approveTymlos 80mcg dose pen injector.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNucynta ER.You asked the Plan to pre-approveNucynta ER. 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-approveNucynta ER.Benefits for Nucynta ERmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEstradiol.You asked the Plan to pre-approveEstradiol. You say that without this you will get chronic urinary tract infections. The Plan denied your request. The Plan says that 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-approveEstradiol.Benefits for Estradiolmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).You asked the Planto pre-approvethe admission. You say that this is medically necessary, as there will be benefit from short term rehab.The Plandenied your request. The Plansaysthe enrollee appears to be more appropriate for long term care with intermittent services.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not support that the enrollee can participate in daily PT and OT. There are no noted daily skilled complex nursing needs. The records do not support the need for daily therapy or the ability to participate in daily therapy due to her advanced dementia.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 admission have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean air ambulance transfer to a long term acute care hospital (LTACH).You asked the Plan to pre-approvean air ambulance transfer to an LTACH facility. You say that the enrollee has needs that require LTACH care.The Plandenied your request. The Plan says the enrollee can continue receiving care in the current facility.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for thediagnosis 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 an air ambulance transfer to an LTACH facility.. Our reviewer says that the requested LTACH transfer is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not show that the enrollee is in need of services which are unavailable at his current location. Therefore, the requested transfer is not shown to be 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 air ambulance transfer to an LTACH facility. have not been met.Therefore, we decided that the Plan does not have to pre-approvean air ambulance transfer to a long term acute care hospital (LTACH).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscriteria has not been met.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 carefullyreview 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 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, skin care,and daily therapy can be provided at a SNF. A ess intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care.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).