Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain or ceramic crown provided on July 8, 2019.You asked the Plan to pay for the crown. You say that your office called the Plan prior to the services being rendered and were told that you were in-network.The Plan denied your request. The Plan says this service was rendered by an out-of-network provider and the enrollee's Plan has no out-of-network benefits.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe porcelain or ceramic crown provided on July 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transportation provided to the enrollee on October 14, 2019.
You asked the Plan to pay for non-emergent ambulance transportation. You say that you are requesting the Plan to reconsider payment due to the services not requiring a prior authorization. The Plan denied your request. The Plan says the provider refuses to send in documentation.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergent ambulance transportation have not been met. The provider refuses to supply clinical or medical information. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transportation provided to the enrollee on October 14, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 18, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you went for a preventive colonoscopy. You say that you were not informed it was considered surgery if polyps were found. The Plan denied your request. The Plan says the copayment 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 $150 copayment for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that two polyps were removed, which is considered a surgical procedure. 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 colonoscopy provided on October 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist orthosis (L3916) provided to the enrollee on September
3, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported.
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 orthosis. Our reviewer says that the
enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the
case file does not support that the requested wrist/hand orthosis was medically reasonable and necessary for the
enrollee in this case. An appropriate history and a physical examination of the wrist would reasonably be
required to adequately assess whether the wrist/hand orthosis was medically reasonable and necessary. The
documentation does not support that the wrist/hand orthosis was medically reasonable and necessary in this
case, as there is no documentation of a credible physical examination of the wrist.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pay for wrist orthosis (L3916) provided to the enrollee on September 3, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the chest (71275).
You asked the Plan to pre-approve a CTA of the chest. You say that the service is medically necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CTA of the chest. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee has a diagnosis of diabetes, hypertension, hyperlipidemia and aortic stenosis. An echocardiogram showed critical aortic valvular stenosis. CT imaging 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 a CTA of the chest have been met. Therefore, we decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the chest (71275).
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiogram provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the echocardiogram. You say that the patient was not enrolled in Hospice at the time of the service. The Plan denied your request. The Plan says Original Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 18, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for an echocardiogram provided to the enrollee on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the TENS device provided to the enrollee on August 14, 2019.You asked the Plan to pay for the TENS device. The Plan denied your request. The Plan says that this is not a Medicare covered benefit.The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered when the above criteria are met.We looked at the file and Medicare rules. The file does not indicate the enrollee was enrolled in a clinical study. Based on this information, we decided that Medicare rules for coverage of the TENS device have not been met.Therefore, we decided that the Plan does not have to pay for the TENS device provided to the enrollee on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 5, 2019.
You asked the Plan to pay for the 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 5, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on September 9, 2019.
You asked the Plan to pay for the mental health services. You say that the services should be covered. The Plan denied your request. The Plan says the services were provided out-of-network and were not emergent or preauthorized.
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 outpatient mental health services provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 2, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that they were unable to discover any evidence of an established relationship between the member and the ordering physician.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on August 2, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray provided on February 28, 2019.You asked the Plan to pay forthe radiology service. You say that the claim was denied. You say that the enrollee was not enrolled in hospice until 4:35 pm and the x-ray was provided at 8:56 am.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe chest x-ray provided on February 28, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided to the
enrollee on August 19, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that the member went to the
hospital and was sent back to his skilled nursing facility by ambulance. You state you were never notified about
the member being discharged and would have picked him up had you known. The Plan denied your request.
The Plan says the claim was processed accordingly with your 2019 EOC 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).
Review of the file show that the enrollee received ambulance services on August 19, 2019. The enrollee is
asked to pay a $325 copayment for the ambulance services. This means that the enrollee has been asked to pay
the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the
copayment for ambulance services provided to the enrollee on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel Sureclick for the enrollee.
You asked the Plan to pre-approve Enbrel. You say that the enrollee has done well on Enbrel. 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-approve Enbrel Sureclick for the enrollee.
Benefits for Enbrel may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on August 20, 2019.You asked the Plan to pay for hearing aids. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the $1000 benefit was exhausted during the processing of the claim for date of service August 20, 2019.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. We looked at the file, and the Plan's rules. You exhausted your $1000 maximum benefit allowance; therefore, the rest of the amount is your responsibility.Therefore, we decided that the Plan does not have to pay for hearing aids purchased on August 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 10, 2019.
You asked the Plan to pay for the 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foreyeglasses on October 10, 2019.You asked the Plan to pay forthe eyeglasses. You say that all services should be covered for the eyeglasses.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.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. We looked at the file and the Plan's rules. You exhausted your benefit allowance, because the Plan paid $125 for your eyeglasses. Therefore, you are asked to pay the remainder.Therefore, we decided that the Plan does not have to pay foreyeglasses on October 10, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary as the
member is declining in function. The Plan denied your request. The Plan says the necessary services may be
provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case 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
needs that could not be addressed at a lower level of care. A less intensive, longer duration of therapy can allow
for measurable gains to be attained within a predicted period.
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued phototherapy (96900 and 96910) after April 9, 2020.You asked the Plan to pre-approve continued phototherapy. You say that this is medically necessary.The Plan denied your request. The Plan says three months of treatment is sufficient at this time.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 continued phototherapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a three months course of treatment is sufficient to determine if this therapy works for enrollee's skin disease.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued phototherapy have not been met.Therefore, we decided that the Plan does not have to pre-approve continued phototherapy (96900 and 96910) after April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case 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 enrollee is presently medically stable. He was treated for alcohol dependence and
drug abuse. Presently, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. There is also no reasonable expectation that this enrollee will be able
to fully participate in and benefit from 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-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea 2mg/0.05ml vial.
You asked the Plan to pre-approve Eylea 2mg/0.05ml vial. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.
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 Eylea 2mg/0.05ml vial. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Bevacizumab would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea 2mg/0.05ml vial have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea 2mg/0.05ml vial.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine for the enrollee.
You asked the Plan to pre-approve Buprenorphine. You say that the enrollee has been stable on this medication. 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-approve Buprenorphine for the enrollee.
Benefits for Buprenorphine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.