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

We decided that the Plan has to pre-approve crowns (D2750) for tooth #'s 22, 23, and 24. You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says that the crowns are not medically necessary for these teeth. 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. The Plan covers the crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that the service is medically necessary. Our physician reviewer found crown restorations for tooth #'s 22, 23, and 24 are medically reasonable and necessary to restore the breakdown of these teeth and to prevent further breakdown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have been met. Therefore, we decided that the Plan has to pre-approve crowns (D2750) for tooth #'s 22, 23, and 24. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveface masks and non-sterile disposable gloves.You asked the Plan to pre-approveface masks and non-sterile disposable gloves. You say that because of your health conditions you need face masks for safetyso you can go outside and to the market.The Plan denied your request. The Plan says the face masks and gloves are not to be used to treat a medical condition.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The itemsat issue in this appeal does not serve a purpose that is primarily medical in nature. The face masksareavailable to the general public and would be helpful even to those who are not sick or injured. Medicare rules say that face masks are categorized as non-reusable disposable items and are not payable by Medicare.The non-sterile gloves are only covered for dialysis services. Therefore, we decided that the Plan does not have to pre-approveface masks and non-sterile disposable gloves.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 18, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you did not touch the medicine and that
the nurse administered it to you. The Plan denied your request. The Plan says these drugs are self-administered
drugs. The Plan also says that these drugs are not Part B covered.
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 pay for the self-administered drugs
provided on February 18, 2020.
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from February 6, 2020 to February 8, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you needed to go to the hospital during these dates of service.The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.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 pay forthe self-administered drugs provided from February 6, 2020 to February 8, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the thorax (71260). 
 
You asked the Plan to pre-approve the CT scan. You say that The CT scan is medically necessary. The Plan denied your request. The Plan says 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 the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the 2017 Fleischner society guidelines indicate 6- to 12-month follow-up scans for a 6mm nodule. No clinical information is provided that supports the need of an earlier follow-up scan. 
 
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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the thorax (71260).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to waive the copayment for the inpatient hospital stay provided from February 14, 2020 to February 16, 2020.You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you already paid a $275 copayment when you were admitted to the hospital. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.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 did not submit a complete 2020 Evidence of Coverage. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment for the inpatient hospital stay provided from February 14, 2020 to February 16, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve face masks.
You asked the Plan to pre-approve face masks. You say that because of your medical issues you need face
masks. The Plan denied your request. The Plan says face masks are not used to treat a medical condition.
The Plan must follow Medicare rules. The rules say that face masks are categorized as non-reusable disposable
items and are not payable by Medicare.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Medicare rules
say that disposable masks are not covered. Therefore, we decided that the Plan does not have to pre-approve
face masks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 23, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you went back because
you were bleeding. You say that no one told you that you would have a copayment. 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 $35
copayment for physician/practitioner services/specialist.
You have been asked to pay a $35 copayment for a specialist office visit. Since services were provided by a
specialist, the correct copayment has been applied. A specialist office visit falls within the
physician/practitioner services/specialist 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 specialist office visit provided on January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on December 19, 2019.You asked the Plan to waive the coinsurance for the Euflexxa injection. You say that at the time of the visits, you were informed there would be no additional charges. You say that you are being overcharged.The Plan denied your request. The Plan says the coinsurance 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 20% of the cost for Part B-covered drugs covered under Medicare Part B.You have been asked to pay $29.71, which is 20% of the allowed amount for the Euflexxa injection. The allowed amount is $148.54 (20% x $148.54 = $29.71). The Euflexxa injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for the Euflexxa injection provided on December 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 30, 2019.
You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says the claim for the service should be billed to Original Medicare.
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 date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the ambulance services provided on September 30, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided
on January 2, 2020.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that a $200
copayment was never mentioned. You say that you were informed your copayment would be $35. 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 $200 for
each type of Medicare-covered diagnostic radiology service including MRI, CT Scans, Nuclear Scans and PET
scans, per date of service.
You have been asked to pay a $200 copayment for the myocardial perfusion imaging. The myocardial
perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging provided on
January 2, 2020.
Your complaint about incorrect information 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: 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 you require admission to an Acute Rehabilitation Facility.The Plan denied your request. The Plan says the provided documentation does not demonstrate a need for complex interdisciplinary therapy. There are no medical issues that would require face to face supervision by an inpatient rehabilitation physician 3 times a week.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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a alternate 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 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 waive the coinsurance for the bevacizumab injection provided on January 9, 2020.
You asked the Plan to waive the coinsurance for the bevacizumab injection. You say that you were previously charged less. You say that the only change is doing both eyes on the same date. The Plan denied your request. The Plan says the coinsurance 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 20% of the plan-allowed amount for in-network, Medicare Part B covered drugs. You have been asked to pay $31.74, which is 20% of the allowed amount for the bevacizumab injection. The allowed amount is $158.70 (20% x $158.70 = $31.74). The bevacizumab injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the bevacizumab injection provided on January 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the skin flap procedure provided on December 30, 2019.
You asked the Plan to waive the coinsurance for the skin flap procedure. You say that it was not discussed that the services would be considered out-of-network. You say that the services should be recalculated as in-network, The Plan denied your request. The Plan says the coinsurance 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 50% of the Medicare-allowed amount for outpatient surgery at an out-of-network outpatient hospital facility. You have been asked to pay $168.20, which is 50% of the allowed amount for the skin flap procedure. The allowed amount is $336.40 (50% x $336.40 = $168.20). The skin flap procedure falls within the "Outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the provider is out-of-network. 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 the skin flap procedure provided on December 30, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehab physician or needs acute rehab nursing care. Functionally given he is at supervision level for mobility, does not need IRF admission. The enrollee may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic magnetic resonance imaging (MRI) services.You asked the Plan to pre-approve the thoracic MRI. You say that the records provided support the need for the requested MRI.The Plan denied your request. The Plan says the clinical information provided does not support the need for the requested MRI.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the thoracic MRI. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the enrollee reported low back and right hip pain with radiation to the groin and thigh but no paresthesia and normal bowel and bladder function. No physical examination was possible for the series of visits when she continued to complain of these symptoms, which were suggestive of a hip etiology and possible lower back. There was no indication from the notes that there was a mid-back or thoracic spine issue such as infection, nerve impingement, fracture, tumor, or other red flag diagnosis which might warrant MRI 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 thoracic MRI have not been met.Therefore, we decided that the Plan does not have to pre-approve thoracic magnetic resonance imaging (MRI) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary.The Plan denied your request. The Plan says the enrollee would more appropriately be treated at their current level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.